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e <br /> CSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. x <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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. 1.862 and the Rules and Regulations of the San ',Joaquin Local Health District. <br /> A) . � L/0—t Vis. 'e-.6 / {alLJ e)r3— {� Q -� <br /> .LOB ADDRESS/LOCATION QST SIDE- -DEvjejtS RE) ,uoff,i H 6r' t0MrA3ejDC6 P-D CENSUS TRACT <br /> Owner's Name e ,La Phone <br /> Address p 7)C:kR)LS Rb City ' An E�)'1 <br /> Contractor's Name San Joaquin Pump Co. <br /> ;,=;asur ce.a . License # Phone <br /> _ - <br /> Lodi, California 95240 <br /> Q <br /> TYPE OF WORK (Check): NEW WELL '/7 DEEPEN '/-7 RECONDITION /7 DESTRUCTION /-T <br /> PUMP INSTALLATION / / PUMP REPAIR ) PUMP REPLACEMENT 1_7 <br /> Other / / 7"r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY-L,INE- - 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 - <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical ` Surface Seal Installed B <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump H.P. 5 <br /> PUMP REPLACEMENT: / / State Work Done <br /> P 1 i. Z /�4° . S.iQ f'�tr.raa.p;_ n �.i�c.:e .,5u cAe�c a---D ... <br /> PUMP .REPAIR: / / State Work Done ,uPc s S�a2 = 2P IA., c <br /> I <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 I= <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 AND A FINAL INSP CTI N. Son Joaquin: Pump Co. <br /> SIGNED TITLE 1pivislon of son Jna uin j <br /> RhM&Ca-1 <br /> (DRAW PLOT PLAN ON REVERSE SIDE 500 E. Kettteman <br /> FOR DEPARTMENT USE ONLY Lodi, Cafifornia 95NO r <br /> PHASE I <br /> APPLICATION' ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: ° <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION i <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> E H 1426 t1nr._ 7. 7/. . L 1.21, M <br />