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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> d <br /> FOV-- OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> � Y Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zz_ 2A.#0 <br /> THIS PERMIT EXPIRES '1 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 6451 OF 0WV1 a 12d y�o.�`�F �oa71 Of CENSUS TRACT <br /> Owner's Name <br /> C/I 5CL IV0-0 Phone C 2,22-Y <br /> Address l 17 Wl � 5 City � Q <br /> San Joaquin Pump CO. <br /> Contractorls Name nr 5 in Sulphur Co. License # 63Z 3o/l—��7/ <br /> . �ticram6nto St. i+ <br />. Lodi, California <br /> TYPE OF WORK (Check) : NEW WELL-/ .I DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> _ I <br /> PUMP INSTALLATION PUMP REPAIR / UMP REPLACEMENT /-T k <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 /> y Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> C Cathodic Protection t Rotary Type of Grout <br /> Disposal - ...Other- Other information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor '.f <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done, / / / <br /> PUMP REPAIR- Sta <br /> _. / te Work .Dane /�e e �2 y",gL,e l e- 76 /a0A N �. <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 FINAL INSPECTSara Joaquin Pump Co. <br /> SIGNED - ION TITLE <br /> D PB T FLAN 'ON RE ERSE SIDE) nr, F. jc ! <br /> FOR DEPARTMENT USE ONLY Lodi, California 95240 <br /> 3, PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/,,FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �,1�' `L ; _ DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />