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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE:6FF_10E USE: fj 160 . E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 t <br /> APPLICATION FOR WELL CONSTRUCT16N OR PUMP PERMIT Permit No. 76=/a//� <br /> THIS PERMIT EXPIRES 1 YEAR .FROM DATE .ISSUED ..r Date, Issued./2 l�`--7� <br /> (Complete In Triplicate), j . ,it <br /> Application is hereby made to the San Joaquin Local health District for a, permit to-:construct - <br /> and/or install the work herein described. This application,is made in., compliance with San Joaquin <br />' County Ordinance No: 1862 and- the Rules and Regulations of, the San.Joaquin Local health District. <br /> ca4S 7 5147 E 0,A- CWC-oe e .Sau 7H eF (Jrjid <br /> JOB ADDRESS/LOCATION yL-,r T .-7-c3Wig.✓!a + ,CENSUS ;TRACT <br /> Owner's Name` !3c l G C?7i0777Y/die_ Phone 3( <br /> Address - City"' ri _ <br /> Sart Joaquin Pump Co. . - <br /> contractor's Name (Bivision of San Joaquin Sulphur Co.) License # fQ Phone 3A 9 q 7! <br /> 711 N. SacramQnta St, <br /> -- -- --- -� _ odi, Califarnia 95240 <br /> TYPE OF WORK (Check): NEW WELL /7. DEEPEN /-7i RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION "% / PUMP REPAIR - UMP REPLACEMENT <br /> Other -L-/ <br /> _ I <br /> DISTANCE TO NEAREST: SEPTIC -TANK . ° '. 'SEWER LINES - ..:..P.I.-.., <br /> .... T PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOASTIC WELL" PUBLIC DOMESTIC-WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS v <br /> Industrial Cable Tool, f Dia. of Well' Excavation <br /> Domestic/private Drilled - Dia. of Well Casing. . . <br /> Domestic/public Driven Gauge of Casing C <br /> . Irrigation ' Gravel Pack Depth of Grout Seal a <br /> Cathodic Pr_otecLion Rotary -� Type of Grout-' <br /> Disposal. Other Other_InfomationT..�._--.�' <br /> Geophysical Surface Seal Installed .8 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _. H.P. r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP IREPAIR: _ /'State Work Done. �u/�- 1�� -�-:i�Rl�cLi✓c� 7�0 1 �i2 J-/ ' <br /> DESTRUCTION OF WELL: . Well Diameter- Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to -.comply with all laws and regulations of the San Joaquin- Local Health District <br /> and the State of California pertaining to or regulating well•construction. , Within FIFTEEN DAYS <br /> after completion of my work on anew well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT,of the well and notify them before putting.the..we11. in-use...: The, above <br /> information is true to- the.best -of my knowledge and belief. I .WILL CALL FOR-A -GROUT INSPECTION <br /> PRIOR TO GROUTING AND A F NAL INSPE N. 5aer .POa ui <br /> SIGNED TITLE q in ,Pump Co. <br /> DRAW PLOT PLAN ON REVERSE SIDE , insion o an oaquin Sulphur Co.). <br /> FOR DEPARTMENT USE ONLY Lodi, Califarnia 9 ' <br /> PHASE I nn { <br /> APPLICATION ACCEPTED BY V J DATE D 1b <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE 'III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE, 1A1 t '7. .._. <br /> E H 1426 Rev. 1...71s F r` h/75 2M <br />