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SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> FOH,OFFIEE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> : .Telephone:. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �6_3 7J., <br /> THIS PERMIT EXPIRES 1 YEAR .FROM DATE ISSUED:: : Date Issued <br /> (Complete In Triplicate).: <br /> Application -is hereby -made in' the San Joaquin Local Health Die triet for. a -permit •to construct <br /> and/or install the work herein described. This appXication is wide in•..compliance with 'San°Joaquin <br /> County Ordinance No. -1862 and the Rules' and Regulations of, the. San•.Joaquin Local Health District.. <br /> F- rsr oAj vicro2 Rara C�+Qk'2�� r. <br /> •uo� 1 ;,, •, <br /> JOB ADDRESS/LOCATION T o V "'.o . t . &wtigCENSU5 TRACT ` <br /> Owner's Name C la(Z L_ I ""�t7% Phone , <br /> Address ILL 90 4LUt Cwcegl - . a 1> City 400 <br /> a <br /> Contractor's Name San Joaquin Pump Co. License # PO-?9P Phone 3b <br /> 1riion of San Joaquin Sulphur Q, <br /> Lodi ' T — •� <br /> TYPE OF WORK (Check): NEF1W&"".2 DEEPEN /? RECONDITION DESTRUCTION f7 <br /> PUMP INSTALLATION L/ PUMP REPAIR/ PUMP REPLACEMENT /� <br /> Other j/7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Ni <br /> , SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL 'CONSTRUCTION SPECIFICATIONS. <br /> Industrial Cable Tool' Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public .Driven-' Gauge of Casing <br /> Irrigation Gravel Pack Depth of. Grout Seal <br /> Cathodic Pr_o•tecr__ion-w-�--�----•Rotary­ Type of Grout _ <br /> Disposal Other ^.Other _Tnformation <br /> Geophysical ,. Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done ' <br /> PUMP-,'REPAIR:� /State work Done 7l? <br />,RES-TRUCTION_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 pertainingto or regulating well "construction. -Within FIFTEEN DAYS <br /> after completion of my work on a new 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 FINAL INSPE ON. <br /> SIGNED - . . ` TITLE Son-Joaquin Pump Co. <br /> DRAW PLOT PLAN ON REVERSE SIDE rnswn o n o gain u p ur o. <br /> N. <br /> PHASE i <br /> FOR DEPARTMENT USE ONLY Lodi,, California 95240 <br /> _ . <br /> APPLICATION ACCEPTED BY ._C DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FI INSPECTLON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 .,Rev. 1-74 _ it h/75 2M <br />