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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> P,OR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. �G-- ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 76-36 0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S_-/ ?-?- 6 <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 •Ordi ance No. 1862 -and the Rules and Regulations of the. San Joaquin Local Health District. <br /> [(g z�'7,�. j ,g2u,�c� �4- " nJ •• <br /> Gins r s i a e �3 r�c:.�.LC -- v c r= e <br /> JOB ADDRESS/LOCATION t e� Pw<ri�..ra1 CENSUS TRACT <br /> �P <br /> Owner's Nam es .J'- _ACc eSe.4-,1 zy . Phone <br /> Address $� / L. . /-Cr '.SC��- f2y/2� _ _ City coo I <br /> Contractor's Name San Joaquin PumpCo. <br /> License 4E Phomze r 7 1 <br /> _ _ Am]�vis att of San Joaquin Sulphur Co.) 36 -,FVf <br /> 711 N. Sacramento St. <br /> Lodi, Calit.rnma ]L <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /7 ;RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / UMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK J. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD r- CESSPOOL/SEEPAGE PIT OTHER <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 iGauge of Casing <br /> Irrigation;.. Gravel-Pack ,Depth of Grout Seal <br /> Other - ' .�_ ._._�-'`'`Rotary �_ :Type of Grout._ <br /> .Other Other'Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /_7 State Work Done ; <br /> f PUMP REPAIR: /::�State Work Done C, ��1�- G"--/ <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 1 <br /> information is true to the best of my knowledge and belief. <br /> SIGNED ( 1 TITLE <br /> Sari Joaquin Pump Co. <br /> (DRAW PLOT PLAN ON REVERSE SIDE hft" °'" <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY Lodi, California 95440 <br /> �f <br /> APPLICATION ACCEPTED BY DATE J�! <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSPECTION v PHASE III/FINAL, INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />