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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFIrE USE: 4�0 Stockton <br /> 1b01 E. Hazelton Ave. , > Calif. <br /> w Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP. <br /> UPERMIT Permit No 7 //��to <br /> MP <br /> THIS PERMTT EXPIRES 1 YEAR FROM DATE .ISSUED Date Issued d 7 <br /> Q (Complete In 'Triplicate) t construct <br /> Application is hereby made to the San Joaquin Local <br /> �GaCiDistrict <br /> for <br /> ptwith San Joaquin <br /> and/or install the work herein described. This applonismade incompliance <br /> CountU <br /> Ordinance No. 862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 03& <br /> Aeva;CS -THac�c� RAS CENSUS TRACT <br /> JOB ON <br /> phone -.13_ILS 6S` <br /> Owner's Name <br /> Address 7 V <br /> V4 c:,r'o 2 D City L O U <br /> Contractor's Name <br /> San Joaquin Pump Co. License # � Phone <br /> insion o an aaqun u p1 ur o. L <br /> �} �. r <br /> TYPE OF WORK (Check) : NEW WLLL 7 D EN� I�l RECONDITION I P�EREPLACEMENT 17 <br /> PUMP INSTALLATION /Z-- UNP REPAIR / / <br /> Other f / <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 /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS \' <br /> INTENDED USE Dia. of Well Excavation <br /> Industrial Cable Tool <br /> Drilled Dia. of Well-:`Casing <br /> Domestic/private Driven Gauge of Casing <br /> Domestic/public ' <br /> Irrigation Gravel Pack Depth of Grout Seal ` <br /> � <br /> Type of Grout <br /> �i <br /> Cathodic ProtectionRotary Other Information ' <br /> Disposal Other _ <br /> Surface Seal Installed B <br /> Geophysical <br /> PUMP INSTALLATION: Contractor ,$. Sd rA) Rum 92 CO 11.P. Z <br /> Type of Pump <br /> / / State Work Done <br /> PUMP REPLACEMENT: <br /> PUMP .REPAIR: / / State Work Done ` <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter 7*Procedure <br /> Describe Material and <br /> cal <br /> ric <br /> I hereby agree to comply with all laws and reg ulatiting,well'-constructs.on.the San' Joaquin LoWithinaFIFTEENtDAYS <br /> and the State of California pertaining to or regulating, <br /> the San Joaquin Local Health District a <br /> after completion of my work on a new well; I will furnish <br /> f 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 AND AMIINSP9�CTIN_ <br /> San Joaquin Pump Co.TITLE <br /> c SIGNED wiseon o : a ' oaquiri utphur Co:? <br /> DRAW T PLAN 'ON RE ERSE SIDE �_.u,., :, ., <br /> FOR DEPARTMENT USE ONLY Lodi, CGMc.rma 9:5ZD <br /> PHASE I C./ DATE <br /> 4 APPLICATION ACCEPTED BY 4 <br /> ADDITIONAL COMMENTS: . PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> r INSPECTION BY DATE ' <br /> 3/76 2M <br /> ' <br /> 9 H 1L?A Rev. 1-74 <br />