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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi flFFIC USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -// 3 P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /_ate.J� <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 /> JOB ADDRESS/LOCATION ale-S7 .51,06- P�r/9G%I?,W6 Y56^1.* OF,44, 'k�ENSUS TRACT <br /> Owner's Name J1 . -S /,/A 006( Phone 360'. <br /> Address d"la 54 /U, jEA- 1,e/V6t1 )7r 119V!�� City �(j,� <br /> Contractor's Name San Joaquin Pump Co. License #?/1� Phone -k3 o21Z/ <br /> Lodi, Califon ' 5240 <br /> TYPE OF WORK (Check) : NEW WELL // DEEPEN / / RECONDITION /_/ DESTRUCTION /� <br /> PUMP INSTALLATION /Lk;;'PUMP REPAIR/ / PUMP REPLACEMENT /_ <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 Surfaces Seal Installed By: <br /> PUMP INSTALLATION: Contractor �A.J �3A,fdcli� PU4t/a C U 6001 <br /> Type of Pump 2 C3�.[S t� H.P. <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 AND A FINAL INSPECTION. $di-I Joaquin Pump Co. <br /> SIGNED TITLE <br /> 211 DRAW PL PLAN"ON RE RRSE SIDE) ` " <br /> -,0 z, Ppa 0 �,, � �r�Pee )DEPARTMENT USE ONLY Loam California 95 40 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: Uy <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> t <br /> .*�.�,�` �:�,�` ��, • '_� 3/76 2M <br /> E H 1426 Rev. 1-74 " '" <br />