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yVf� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F08rOFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <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 !-LS-2r <br /> (Complete 1n� Triplicate) F <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 /> �1ic/L7-H S'..o6 o F $ mj 4C koi;0 &At_r 0 F 441*- a V <br /> JOB ADDRESS/LOCATION nc,c .A, CENSUS TRACT <br /> Owner's Name /a . �. "r ct ck L C,cu.,s Phone =� , <br /> Address4 r u,eAJ 5 r }' City S Tc:c k 7 0AJ <br /> Contractor's Name Soap Joaquin Pump 'Co. �� } <br /> License # Phone <br /> Lodi, California 40 v �� <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /? RECONDITION /7 DESTRUCTION /7 <br /> AL ' <br /> j PUMP INSTLATION PUMP REPAIR /_7ME <br /> PUMP REPLACENT ' <br /> Other /_7 <br /> t <br /> A <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 S <br /> Ddmestic/private Drilled <br /> Dia. of Well Casing <br /> Domestic/publictl Driven Gauge of Casing r <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> „ Cathodic Protection Rotary Type of Grout <br /> Disposal .y .: Other Other Information <br /> Geophysical .' <br /> Surface Seal Installed BX: <br /> PUMP INSTALLATION: Contractor <br /> �. <br /> Type of Pump <br /> PUMP REPLACEMENT: / 7 State Work Done .` <br /> r.PI7MPIMPAIR: /7 State Work Done . <br /> ES.TKUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material, and Procedure <br /> O <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 Distri <br /> WELL DRILLERS REPORT of the well and notify them before putting the- well in use. The above ct a <br /> information is true to the-best of my knowledge aiid belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPESIGNED ION. i <br /> i TITLE Son Joaquin Pump Co. <br /> oil <br /> (DRAW PLOT PLAN ON REVERSE SIDE '--"�:" '”' •J <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Lodi, California 95240 <br />_ <br /> APPLICATION ACCEPTED BY Gs� X13: DATE r <br /> ADDITIONAL COMMENTS: �" j- ' <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> Aze� CV <br />`INSPECTION BY DATE INSPECTION- BY DATE_7X,7131 <br /> E H 1426 Rev. I-74 <br />