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l r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. ' <br /> � Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: 77' /� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> r (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 /> JOB ADDRESS/LOCATION SA&47-114je5 Leo_ utf�� 8hde 91-1 Halt S _ CENSUS TRACT <br /> ° Y. Phone 3 <br /> Owner's Name R # F_ <br /> �? <br /> E `T la LA - <br /> r Address g 7C 7 q /U s (�{tl 9 k City ,57o Gk-7e1t/ <br /> San foaquin Pump Co. <br /> r License fir` 37,yPhone 7 <br /> I Contractor s Name {Division of Son Joaquin Sulphur Co.) <br /> _711 N. Sacranlcnto St. <br /> maurrlun 7577 <br /> FTYPE OF WORK (Check) : NEW WELL/ 1 DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION /�./ 'UMP REPAIR / / PUMP REPLACEMENT J7 <br /> AL <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 �n <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 rof, Grout. Sea]' <br /> Cathodic-Protection. - ``v _Rotary -`;-""' — .Type of-GroutT - <br /> Disposal Other 'Other •Information <br /> Geophysical Surf ace�-Seal Installed. By: <br /> PUMP INSTALLATION: Contractor o4A.,' +u �Q <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PtiJMP:REPAIR:°���- .�� `/"�'/"`�•ta•te~-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 /> i after completion of my work on a new well, I'will furnish the_ySan .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 GRO AND A-FINAL ,TNSPEcriw. San Joaquin Pump Co. <br /> SIGNED TITLE <br /> ! DRAWPUOT PLAN ON REVERSE SIDE) ' , <br /> ! FOR DEPARTMENT USE ONLY Lodi, Ca9ifarrlia 9521M <br /> PHASE IDATE - ' y.= <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY.- DATE INSPECTION BY DAT <br /> RAe- <br /> 3/76 <br /> E H 1426 Rev. 1-74 ''w _-- <br />