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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 6 <br /> FOF 0 FFTCP' USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 /- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.V` IY45 <br /> _ THIS PERMIT EXPIRES 1 -YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) ",rj : 0 3 -090 -S V <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 /> 4 flj T 7'o ""'00a$quo Ge C00,%jC4,j <br /> JOB ADDRESS/LOCATION rxy_ V44 V- ,vog77/ 7-,-4,/,#/CENSUS TRACT <br /> Owner's Name ALis Lam+ _ i� Phone <br /> Address <br /> '/�1�, City <br /> f San Joaquin PUMP co'. k <br /> Contractor's Name (Divisian of Son Irutr� ;�Cu;phee- License �� 1() 7 <br /> Phone <br /> 711 N. Sacrarre <br /> �. <br /> Lori, Caii;ornia <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> tl, r <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 C <br /> Domestic/private Drilled p -Dia. .of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary b Type of Grout <br /> Disposal r Other Other Information <br /> Geophysical. Surface Seal Instal.led, By: <br /> } <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. Z <br /> PUMP REPLACEMENT: <br /> /�/ State Wank Done <br /> PUMP-REPAIR: - —_/,./ State_Work`Done- <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 CROyjjAg AND A FINAL _LbllSiF EC 0 San Joaquin Pump Co. <br /> SIGNED TITLE (Division of Son 1uaquin Sulphur Co,) <br /> -(DRAW PLOT PLAN ON REVERSE SIDE) 711 N. Sacrament�j a. <br /> F R DEPARTMENT USE ONLY o i, c.t a.rl"Id 5D7 <br /> PHASE I <br /> APPLICATION ACCEPTED BY L DATE <br /> ADDITIONAL COMMENTS: { <br /> PHASE II GROUT INSPECTION PHASE I /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M <br /> E H 1426 Rev. - 1-74 of77 - } <br />