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SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> F08+OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zy 7jo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-2,5--1,5- <br /> (Complete <br /> -25=1(Complete In Triplicate) <br /> Appiica ion 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 Joaquiti" <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ERS7- .5-10f Or5p, RR, Zoo +c, 3 eo $-&S <br /> JOB ADDRESS/LOCATION ,dya27;! 0,— iV C,9M.-70 ,D CENSUS TRACT <br /> Owner's Name C�E,p IVqg i4 TF; Phone <br /> Address <br /> San oaqu City fl 0 <br /> Contractor's Name lDtvision of Son Joaquin Sulphur Co.) License # Phone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /7 DESTRUCTION /? <br /> PUMP INSTALLATION L7 PUMP REPAIR � PUMP REPLACEMENT <br /> Other /-7 <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 4 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACENENTt L/ State Work Done <br /> PUMP REPAIR: f State Work Done Rfiv°R k Pomp 6464v14 ¢ R �tiS T.14L w �E <br /> ry <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 thewell in use.. The above <br /> information is true to the beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. San Joaquin PUMP . <br /> SIGNED � TITLE W_1ginn of <br /> San Joaquin SuW1ur c°°' <br /> DRAW PLOT PLAN ON REVERSE SIDE 00 E. Kett enlan <br /> FOR DEPARTMENT USE ONLY Lodi, Ca i ornia <br /> PHASE I <br /> APPLICATION ACCEPTED BY e� DATE /-7--d//5 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRJOUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY DATEINSPECTION , <br /> INSPECTION <br /> ,l E H 1426 Rev. 1-74 <br /> 1-71r-2M <br />