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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> poE OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209). 466-6781 <br /> z ;3'AP•PLTCATTON FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7z 6s4/a <br /> { ANEW,. , <br /> r THIS PERMIT EXPIRES 'l YEAR FROM DATE:TS d ? 7 J6 <br /> k c} .� {Complete In Triplicate) <br /> f Application is hereby made3,to the San Joaquin Local Health District far a permit -to, construct <br /> and/or install the work,"he�rein described. This application is-made in compliance with San Joaquin <br /> County OrdihaAce No. 1862 and the Rules 'and Regulations of `the San.Joaquin =Local Health District. <br /> JOB ADDRESS/LOCATION �" 56-E- leyCe € CENSUS TRACT <br /> Owner's-,Name i -4-u m aX)C fJ iULl2���Y _._.__._ Phone <br /> s <br /> Address /S 7/ Z /Q , LC��!J --•- . _ City <br /> ` 0,0Zf �agis�"in Pump Co. Sf 7/ <br /> �. .gontract:or'-s.-Name a(Division-of Son Joaquin Sulphur Co.) License # 3,/&-3.J--Phone- -J <br /> 711 N. Sacramento <br /> F TYPE OF WORK (Check) : NEW WELL '/7 DEEPEN17 7 RECONDITION /_7 DESTRUCTION /-J <br /> AL <br /> PUMP INSTLATION / J PUMP REPAIR .17 PUMP REPLACEMENT <br /> Other / / <br /> f — <br /> DISTANCE-TO NEAREST:' SEPTIC-TANK SEWER!LINES µPIT PRIVY <br /> I 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 /> f Industrial Cable Tool Dia. of Well Etcavation Cn <br /> Domestic/private Drilled Dia. of Well. Casing <br /> 4 � Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection = Rotary Type of Grout ' <br /> Disposal Other Other Information ' ' <br /> Geophysical k Surface Seal 'Iristall,ed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of. Pump € - H.P. <br /> " PUMP REPLACEMENT: . / tate Work Done �/ �• �'BC ifs�� -2 <br /> c <br /> � EPAIV11MP <br /> R�: - _}RJ !/j ' State__� _r _ 4..-..� - J.jM�r,r—..-wec'• —i y- — '..11.nr'^_. <br /> -,R — Work Done <br /> ,DESTRUCTION OF WELL: Well .Diameter ' i 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 d'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..knowledgeand belief. I.WILL CALL -FOR A -GROUT- INSPECTION <br /> PRIOR TO GROUTING 'AND A FINAL INSP>1 XO Sba Joaquin Pump Co. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY Lodi, Colifarnia 95240 <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY DATE 2 L3 % <br /> ;ADDITIONAL COMMENTS: <br /> I PHASE lI GROUT INSPECTION PRASE IIT FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY., DATE d <br /> 4t 75 2M <br /> E H "1426 Revs 1=74 <br />