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SAN JOAQUIN LOCAL HEALTH. DISTRICT , <br /> FOR`OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 /I14� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.2, -{ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,6-J <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 applicationfis made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rule and Regulations of the San Joaquin Local Health District. <br /> ��i�� T <br /> JOB ADDRESS/LOCATION 64s: Si4F Of 0ux7-.y Qe7id- W 06-c,7-jec 3'A mA-jT CENSUS TRACT � <br /> Owner's Name_ I'2 A Y D1-1yGA1 Po2T Phone 3_ - .-- 68 _ 77,57V _ <br /> Address _ 2.3 3 2,q- IV, -0u.5 -re-J !Z'D City A.cryr vPp__. <br /> Contractor's Name Son Joaquin Pump Co. �f�7� <br /> San �,. ,�,,, s,d„n�.ce.� License ��, 037� Phone <br /> �•1 Snc• ;�7�rz4n $t <br />_ t <br /> Lodi, Czt4farnic 9.3240 <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN '/7/ RECONDITION /% DESTRUCTION /- ; <br /> PUMP INSTALLATION / ;. - PUMP REPAIR / / PUMP 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 <br /> Industrial p 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 Informationm <br /> Geophysical Y Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor `Siy:J T ,a ur..s PIARcj2 CO. <br /> Type of PumpH.P. 3 <br /> PUMP REPLACEMENT / / State Work Done <br /> 4 <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 GROUTING AND AL INSPECTION. <br /> SIGNED I / TITLE San Joaquin Pump Co. <br /> DRAW' 'I' PLAN 'ON RE FRSE SIDE iwsion o pnquin 3101p,"Ur; <br /> jM <br /> FOR DEPARTMENT USE ONLY <br /> Lodi, Caiifurisia 95240 <br /> PHASE T DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II .GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY .] DATE ZZ <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />