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-�� SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I <br /> THIS PERMIT EXPIRES 'l YEAR FROM DATE ISSUED: Date Issued <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ` A j fe. .voZ r4 OF- 5- Z I CS S,214 , US TRACT <br /> Owner's Name A�, s��/ ^ Phone -3 -4 2 1 <br /> Address / d, 0,-j&/$ A�?,D City ,60,0 <br /> San Joaquin Pump Co. ! <br /> Contractor's Name License �� Phone �'- <br /> _ �D;v;�;nn�f_San lo9uuin-SulFhur Co,� ;�� 11 7 <br /> 711 N. Sacramento St. <br /> Lodi, California 9524U <br /> TYPE OF WORK (Check) : NEW WELL / 7 DEEPEN '/ / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR /U,;7�UMP REPLACEMENT /� <br /> Other / / _ — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 � f <br /> Cathodic Protection Rotary Type of Grout { <br /> Disposal Other Other Information l <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor s <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> i <br /> { <br /> PUMP .REPAIR: State Work Done /T�,BU/�� D/�1� fo , 5/z .E'�1'co AL"!Mi <br /> 4 r <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 "Chem 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 IN " ECrION, San Joaquin Pump ®, <br /> SIGNED TITLE <br /> CZ (DRAW- PL T PLAN ON REVERSE SIDE) } <br /> FOR DEPARTMENT USE ONLY Lodi, California 95240 <br /> PHASE Ie- <br /> DATE ACCEPTED BY - DATE /;2 -?� T <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE JII/SINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 71 <br /> E H 1426 Rev. 1-74 3/75 2M <br />