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Y <br /> _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72_ .A15--f110 <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 /> 69-57- <br /> JOB <br /> 9-57JOB ADDRESS/LOCATION _O o A,,dQ�Es ed L-A a- oazee.- xec,e wflcf) CENSUS TRACT <br /> i <br /> Owner's Name D F rA Rs A __ -� so � . A5 vglels Phone <br /> i <br /> Address 7 S-O Gtr, f/. r,70,2 IeD City G d.0 / <br /> San Joaquin Pump Co. License �� : 137 Phone - 5�7/ <br /> Contractor r s Name ��:.:,,,, ..r S,,, c.._,,..:,,_, <br /> •a <br /> Lodi, Califarnia 9 ?40'.: <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION DESTRUCTION DESTRUCTION /_7 � + <br /> AL <br /> PUMP INSTLATION REPAIR /L/IPUMP 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 1 .1 <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private , Drilled Dia. of Well Casing ' <br /> -.Domestic/public . Tx Driven Gauge of Casing. <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other y Other Information { <br /> -Geophysical Surface Seal Installed By:_ <br /> PUMP INSTALLATION: Contractor 6- - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: -/Z- ?;`State Work Done We e/ I Auns <br /> ._ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> Describe Material and Procedure <br /> I <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 INAL INSPECTION. San Joaquin Pump Co: <br /> SIGNED TITLE V <br /> W PLOT' PLAN ON REVERSE SIDE) s <br /> FOR. DEPARTMENT USE ONLY Lodi, California 95240 <br /> PHASE I �'f <br /> APPLICATION ACCEPTED BY �y , _. DATE '�"I T2 o 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE //- -a_ <br /> I <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />