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,. ' SAN .sOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> FOV OFFICE USE: 1 <br /> Telephone: (209) x+66-6781 Permit No. ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT i <br /> THIS PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) ct <br /> trict <br /> Application is hereby made to the San- Joaquin Racal HealthDismade inrcampliancetwith ganuJaaquin <br /> and/or install the work herein described. This application <br /> and Regulations of the San Joaquin Local Health District.. <br /> County Ordinance No. 1862 and the .Rules f <br /> JOB ADDRESS/LOCATIONA ?" <br /> �<!/Y� 10 Ad)vV okd J I mVPltrilP CENSUS TRACT <br /> 11 f(?f z 21r Phone <br /> Owner's Name Cls <br /> Y City 5;qCd�'/�/YlET�; <br /> Address <br /> License # (}.�] Phone ; a <br />'k 'Contractor's Name San Joaquin Purna.co. CONDIT <br /> DSTRUCTION <br /> .E�.OF�WORK (Check) : NEW WELL ./ / DEEPEN / IPEREPAIRI/N// PUMPEREPLACEMENT� <br /> TY.P <br /> PUMP_INSTALLATION /, fTPiTM <br /> 0 tler <br /> -�- rA <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 /> Drilled Dia. of Well Casing <br /> Domestic/private 09Driven Gauge of Casing en <br /> Domestic/public <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> T e of Grout <br /> Cathodic Protection Rotary her Information <br /> Disposal Other <br /> ,._ Surface Seal. Installed B <br /> Geophysical <br /> PUMP INSTALLATION: Contractor H.P. ; <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> _ � -1 <br /> :.-�- - .-.-_. _ „" _ . . ,- Approximate Depth �..�.�. <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> l s of the San <br /> I hereby agree to comply with all laws and oreg� aang wellconstxucgtion.LaWithcal �inaFIFTEENtDAYS <br /> and the State of California pertaining to g <br /> after completion of my work an a new we Ithemlbeforefurnish <br /> puttingthe�wellninLocal <br /> useHeThet1above <br /> xrct <br /> WELL DRILLERS REPORT of the well and notify <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 LrF <br /> INSPEC ION. TITLE San Joaquin Pump �o, '� <br /> SIGNED odqu:n ��iphur Ca.J <br /> (DRAW T PLAN ON REVERSE SIDE) sY <br /> FOR DEPARTMENT USE ONLY Lodi, California 95240 <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION IiVSF1JCTIDN BY DATE <br /> } INSPECTION BY DATE <br /> f <br /> b/77— 2M <br /> r rt..�ti Dn . 1-71L <br />