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_ SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> OE` <br /> FOFFIJE USE: &)5J1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 22- 3gil <br /> i THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedy � - <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 Joaquin <br />! County Ordinance No. 18 62-and the Rules and Regulations of the San Joaquin Local Health District. <br /> .Y7 ' _ <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION _�5�� f: - ---- <br /> Owner's Name J ` .fJ.vO � Phone <br /> Address ,2 7 City -- <br /> fan Joaquin Pump Co. License # <rPhone . - <br /> Contractor s Name {Division o sari Janauin Sulphur Co.) <br /> 711 N. Sacramorito St. <br /> Lodi, Cali#a:rhla 9514 <br /> TYPE OF WORK (Check) : NEW WELL J / DEEPEN /_/ RECONDITION / /� DESTRUCTION f7 <br /> "PUMP INSTALLATION / / PUMP REPAIR/ PUMP REPLACEMENT 1_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> r SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . - <br /> Industrial <br /> PECIFICATIONS Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing V <br /> i Domestic/public Driven Gauge of Casing V <br /> Irrigation 'Gavel`:P cic, Depth- of Grout Seal <br /> Cathodic Protection Rotary -Type of Grout <br /> DisposalOther Other Information ' <br /> i Geophysical Surface Seal Installed By, <br /> PUMP INSTALLATION: Contractor <br /> Type- of Pump H.P. <br /> PUMP REPLACEMENT! State Work Done <br /> PUMP .REPAIR: /� State Work Done �d /�V � �ue f'W� <br /> .. : S <br /> DESTRUCTION OF WELL: 'Well Diameter Approximate Depth <br /> Describe Material. and Procedure <br /> tY hereby agree to comply with all laws anal regulations of the San Joaquin Local Health District <br /> and the State of Califorriia pertaining to or regulating well'�cbnstruction. 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 GROUTI D A FINAL INSPECTaD Joaquin Pump Co. <br /> SIGNEDTITLE <br /> DRAW tbT PLAN ON RE E'RSE SID <br /> FOR DEPARTMENT USE ONLY Lodi, Caii'fo-Mia 95 40 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE { <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIOA P SE III/FINAL I SPECTI N <br /> INSPECTION BY DATE INSPECTION BY �`_,d DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />