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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: (ice 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;26 /D a 6)4 <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 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 /> 7- Aze.-vs o &),es f sl o e a i- hid <br /> JOB ADDRESS/LOCATION .yeX %o Ro.nj S ev cr'ry of GAJ CENSUS TRACT <br /> Owner's Name .3, GUS/ ,ot'RIZI CA- Phone <br /> Address 1 q- E 6C C r 7-6 C m�.c3 GAJ City L q 4.? If <br /> Son Joaquin Pump Co. ` <br /> Contractor's Name 44,c.nn•nf Snn Jnnquin Sulphur Ca.) License # 7/03/ kPhone 3 �1-��06 <br /> 711 OV° Saacromerto St° <br /> Lodi, Cci1'tta. nio 95210 <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN / / RECONDITION /—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR UMP REPLACEMENT /7 <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done / / <br /> PUMP .REPAIR: /�„�'' State Work Done 14d e lu ti 7c) / A/P <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> acr— <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 AND A FINAL INSPECTION. <br /> SIGNED TITLE San Joaquin Pump Co. <br /> W PLAN 'ON SE SID ivision of San oaquin u ur e. { <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IC�ai�,oynia 95210 <br /> ` <br /> APPLICATION ACCEPTED BY DATE /6 226 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II F ;NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE :. <br /> E H 1426 Bev. 1-74 '' <br /> 3V76 2H <br />