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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 70rl- OFFICE 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 -/7- '7,9 <br /> � (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 fegulations o theaaU Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO CENSUS TRACT <br /> Owner's Name 14L)Cr es uc t� ltR 4� Cis f i�► Phone <br /> P•, <br /> Address 01 4% E PN @ C-"2.0 City C� ►J f <br /> Contractor's Name SAN License # p 7S'Phone l _ 7/s <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION / j ¢ <br /> PUMP INSTALLATION / :� PUMP REPAIR / / PUMP REPLACEMENT /� V <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 <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 Iu�e; <br /> Type of Pump 'Tu�jZ,6 •fr H.P. �2 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State 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 /> 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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ,&D A FINAL INSP CT ION. <br /> SIGNED TITLE SAN JOAQUIN PUMP COMPANY <br /> - <br /> (D PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY P. 0. BOX 201 <br /> PHASE I Lodi, JJ Vnia 95240 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROU NSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE _ Ct <br /> _ 2M <br /> E H 1426 Rey . 1=7 -- <br /> 6/77 <br />