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�p k <br /> .. SAN JOAQUIN LOCAL HEALTH DISTRICT u <br /> r. FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> t <br /> Telephone : (209) 466--6781 <br /> i# APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> � (Complete In Triplicate) �� ( - / 33-�-J <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 /> 4t4SS/LOCATION CENSUS TRACT <br />` Owner'fs Name Phone <br />` Address l / 0 city <br /> , Gyp/ <br /> !E!E <br /> IE` _Contractor's Name �ee� lamuin Pump Co. License # Phone 9`7 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION - / -DESTRUCTIO.N.�/�_ <br /> __ <br /> PUMP INSTALLATION /�f- PUMP REPAIR / / PUMP REPLACEMENT_ <br /> Other <br /> DISTANCE- TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> Ij SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I� PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> !!INTENDED USE TYPE OF WELL t CONSTRUCTION SPECIFICA_ TIO_NS_ W . <br /> IIndustrial Cable Tool Dia.' of Well Excavation <br /> !Domestic/private Drilled Dia. of Well>Casing <br /> !Domestic/public Driven Gauge of Casing <br /> lflrrigation = Gravel Pack Depth of Groiit Seal k <br /> jCathodic Protection Rotary [ Type of Grout y <br /> Disposal Other Other Information <br /> Ceophysical Surface Seal Installed By: <br /> i PUMP INSTALLATION: Contractor <br /> Ii Type of Pump _ �.�,G�•uC H.P. <br /> 4 _ <br /> I <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -. PAIR: / / State Work Done <br /> I <br /> EDES-TRUCTION OF WELL: Well Diameter Approximate Depth b <br /> E Describe Material and Procedure <br /> I herdby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> E and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> afterjhcompletion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WILL DRILLERS REPORT of the well and notify them before putting thewell 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 GROUT! D A FINAL INSPECTION. <br /> SIGNED TITLE Son Joaquin Pirmp Co. ppplll" <br /> W PLOT PLAN ON REVERSE SIDE) (Division of San Joaquin Sulphur Co.) <br /> FOR DEPARTMENT USE ONLY acraman o t. <br /> PHASE iii Lodi, California 95240 <br /> APPLICATION ACCEPTED BY, DATE <br /> a <br /> ADDITIONAL COMMENTS: <br /> E PHASE II GROUT INSPECTION PHASE III/FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY _ �' , DATE f 71 <br /> f, <br /> 2M <br /> E H 1426 Rev. - I-74 <br />