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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.?�z <br /> f <br /> Telephone: (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -7 <br /> } (t;omplete . In Triplicate} o�d <br /> Application is hereby made to the San Joaquin Local Health District for a- permit to construct i <br /> and/or .install the work herein described. This application is} made.in compliance with San <br /> Joaquin County .Ordinance No. 1862 and the Rules and Regulations-..of the San- Joaquin Local Health <br /> District. southeast corner of ;Harney Lane & Clements Rd . <br /> EXACT.- STREET ADDRESS Center of W/W V of section 23 t.-3n '-& r-8E CITY/TOWN ' Lodi <br /> Owner's Name Mc Cakthy Land co . Phone 252-3731 <br /> Rresno Address. ,... 4962 E . University _ � -_Cjty.�. m <br /> Contractor�s,Name B & W Drilling License# 339912 Phone 4411401 <br /> 'SIS CERTIF:ICATEr OF..W.OPKt1All'S _COt4PENSATIO�,1 _ItISURA"10E ON FILE WITH SJLHD?- -YES-t- Y = 0 <br /> TYPE OF WORK (Check) : NEW WELLIZ DEEPEN ❑ -RECONDITION ® DESTRUCTION.[� <br /> WELL -CHLORINATION ❑ WELL ABANDONMENT ❑ OTHERF-3 <br /> PUMP_INSTALLATION E7 PUMP REPAIR❑ PUMP REPLACEMENT-El <br /> �DI_STANCE TO NEAREST: SEPTIC TANK x SEWER LINES x. PIT PRIVY x � (N <br /> i� SEWAGE DISPOSAL FIELD v . CESS OL/SEEPAGE PIT OTHER mil <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLI DOMESTIC WE •1 <br /> ` INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial aCable Tool Dia. of Wel Excavation ++ <br /> Domestic/private Drilled' Dia. of Well Casing 16' ° <br /> � i Domestic/public Driven Gauge of Casing 990 <br /> 1: X x rrigation Gravel Pack Depth of Grout Sea none <br /> x <br /> :1 Cathodic Protection x Rotary Reverse Type,.of Grout <br /> iDisposal Other Other Information 1 <br /> ft Geophysical Surface Seal Insta ed b .. <br /> PUMP. INSTALLATION: Contractor _ B Dpi n PT <br /> Type of Pump Turb ine R.P. 3 Q De-Velppix <br /> RUMP 'REPLACEMENT: State Work Done Engine <br /> .PUMP REPAIR: Q State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth. - <br /> Describe <br /> epth• -Describe Material and Procedure y <br /> I hereby certify that I have prepared this application and that the work will be done to accordan <br /> with San Joaquin County Ordinances , State Laws, and Rules and Regulations of the.-San Joaquin, Loca <br /> Health District. Home owner or licensed agent' s signature certifies the following: <br /> "I certify that in the p6rformance of the work :for which this permit is issued, I shall <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> laws of California. <br /> I WILL CALL FOR A GROUT INSPECTIQbl2PRIOR TO GROUTING AND A' FINAL INSPECTION. <br /> SIGNED B & W Dril ling By : TITLE: President DATE: -12-2"9-78 --' <br /> C a N ON REVERS SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . . . <br /> IA`PPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> J. ' PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ."SPECTION BY . DATE INSPECTION BY r. DATE <br /> '-�4 26 Rev. 9/78 - x.78, f2M.- <br />