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Cf 4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. G <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1 7 I <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 instar 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 /> $eTcucca.� <br /> JOB ADDRESS/LOCATION _� _LlJoB�JgeE �a �g�- /�oye��� CENSUS TRACT <br /> Owner's Name _ phone ool 7 <br /> J <br /> Address _ 3 7 V7CPJ� 2;2.0��i0 �O' —. City (�O� <br /> San Joaquin Pump CO. License # / 3 Phone � kY 7/ <br /> Contractor's Name (M;,lcion n4 ;on Jo auin Sulphur Co.) __ <br /> 1 N. Socramenia St. i <br /> Lodi, Caiifarnio 952140 <br />` TYPE OF WORK Check NEW-WELL /77[ DEEPEN- RECONDITION RECONDITION /' / `DESTRUCTION - <br /> - <br /> I PUMP INSTALLATION R// I PUMP REPAIPUMP REPLACEMENT /-7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF. WELL�, - CONSTRUCTION SPECIFICATIONS .: V: <br /> E Industrial 1 Cable Tool p Dia. of Well Excavation <br /> Domestic/private 1 Drilled ' - , Dia. -of Well Casing,. <br /> Domestic/public _ ! Driven _ Gauge of Casing .� <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal „ +. Other Other Information <br /> Geophysical �� Surface Seal Installed By: <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type sof Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> Pu// -7L h�F , <br /> PUMP .REPAIR: /c r State Work Done sT A) Aae <br /> DES-TRUCTION 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 myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING FINAL INSPECTION. <br /> SIGNED TITLE San Joaquin Pump Co. <br /> D OT PLAN ON REVERSE SIDE Division of Snn'Jocgoin 5 pliur <br /> FOR DEPARTMENT USE ONLY ` cal.m nca r' <br /> PHASE I Lodi, Califarnia 9jZ40 <br /> APPLICATION ACCEPTED BY DATE '0 -3- <br /> ADDITIONAL. COMMENTS: <br /> PHASE II GROUT -INSPECTI& PHASE III FINAL INSPECTION <br /> INSPECTION, BY� DATE INSPECTION BY ll - DATE//-ZY '9 7 <br /> P <br /> I 3/76 2M <br /> E <br /> E H 11426 Rev. '1-74 _ <br />