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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR OFFICE USF-: - <br /> _ � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> l i 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 iL- 3 _7� <br /> (Complete In Triplicate) , <br /> Application is hereby made to the San Jo1. aquin Local Health District fora permit to construct <br /> and/or install the work 'heren described. This application is made .in :compliance with San Joaquin <br /> Count Ordinance No. 1$6 _anc� the Rules and Regulations of the San Joaquin Local Health District. <br /> Y _ _ .� <br /> i fe.�D_D�N�: .� <br /> JOB ADDRESS/LOCATION ��/� so4erll ex- di,!�Toe .Pd .* , <br /> CENSUS TRACT 4S/•-370-L3 <br /> Owner's Name <br /> Phone 3 -Jl`Q/c5 <br /> Address 7 city GD.Oi <br /> Contractor's. Name San haquin pump Co. License # Phone <br /> nsion of Sart Joaquin Sulphur Co.) v <br /> TYPE OF WORK (Check) . <br /> - E °!IL4(bEEPEN _ <br /> DESTRUCTION I� <br /> PPUMPrINSTALLATION / / PUMP REPAIR /�c../ UMP REPLACEMENT /_7Othe <br /> 'I <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER. LINES PIT PRIVY 4 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERT� LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Ad <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private ( Drilled , <br /> Dia. of Well. Casing <br /> Domestic/public ` Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of-Grout Sear <br /> Cathodic Profecti`o -"Rotia'ry " - -� Tape of Grout <br /> Disposal Other Other In€ormation <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION; Contractor <br /> . ' <br /> Type of Pump .. - <br /> H.P. <br /> PUMP REPLACEMENT: <br /> / / . State Work Done <br /> PUMP REPAIR: <br /> . . . /state,Work. Done. <br /> DESTRUCTION OF WELL: Well Diameterx <br /> Approximate Deptti6 <br /> Describe Material and Procedure — <br /> --�-- <br /> Ihereby agree to comply withal 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 ori 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 INSPECTIO , <br /> SIGNED ? TITLE Sort 3uin Pum Co. <br /> (DRAW r T FLAN ON REVERSE SIDE) (Dirisi•n•f;Sin 7oaquirr ulphur Co.). 7 <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY acramen o <br /> � ' <br /> APPLICATION ACCEPTED BYLodi, CaEifarnea 95240, k / <br /> ADDITIONAL COMMENTS: DATE <br /> 1 <br /> PHASE II GROUT INSPECTION PHASE ITI/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />,u E H 1426 Rev. 1- � yy, - f~ F <br /> 74 S-� 7� 3/76 2M t <br />