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- � SAN-JOAQUIN LOCAL HEALTH DISTRICT .; • <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '75-A4. 2,0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Isstied-;?-�L2-7T_ <br /> (Complete In Triplicate) <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 J'oaquiri <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District: <br /> JOB ADDRESS/LOCATION S. t'C C,Z2.11C4 iia► CENSUS TRACT <br /> Owner's Name 'D ,L,O t ra -r-).o U CP Phone <br /> r <br /> Address i ti . . GAG l R city A CA MP o <br /> San Joaquin Pump Co. '-��]� <br /> Contractor's Name � "on Joaquin Sulphur Co.) License Phone <br /> - W E: Kettleman - <br /> . 1 <br /> Lodi, California <br /> TYPE OF WORK (Check) : NEW WELL. /-7 DEEPEN "/? RECONDITION /T DESTRUCTION %j <br /> PUMP INSTALLATION / / PUMP REPAIR,/ PUMP REPLACEMENT /7 <br /> Other E7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD t CESSPOOL/SEEPAGE PIT OTHER = <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL h CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> „, Domestic/private Drilled s Dia, of Well Casing Q <br /> Domestic/public Driven ?Gai ge'oof Casing <br /> Irrigatio> r"�"�" "` �Gravel`Pmc _.. Depth of Grout Seal <br /> Cathodic Protection _�, Rvtay ". Type of Grout <br /> Disposal A Othf;r Other Information <br /> Geophysical i Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor 3 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done #. <br /> PUMP•:REPAIR-: -/Vf State Work Dorfe-paij, <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 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".well. 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 INS CTION. ori joaquin Pump Co. <br /> SIGNEDc G TITLE (Division of San Joaquin Sulphur Co.) <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTER BYDATE o2/ 71 1 <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT INSPECTION PHASE III FINAL INSPECTIQN <br />, INSPECTION BY DATE INSPECTION BY DATE <br /> E_H_M6% Rev. ^1 74 ;- h/75 <br />