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G SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) .466-6781. ` <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. YJa,SSp <br /> THIS PERMIT EXPIRES 1 YEAR PROM`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 /> ,64S7- <br /> JOB <br /> ASTJOB ADDRESS/LOCATION DF LG.ara .vew-r- rc] Igo4tD CENSUS IRACCT' <br /> Owner's Name x77 f1 Gl 2/Ccs & .,'7/wfX g5Ee Phone , 0 ' 797 -- <br /> Address ;Z /. !6 9 /U= A&RU 6.444 1240 City 4 A_ P-1P6 <br /> ��Saw Joaquin Pump Co. p <br /> Contractor's Name 449.4 ;nn of son 1nanuin Sublur Q.) License. # /G3 7 Phone " a y7� <br /> ---— - -- - -- 711 N. Sacramento St. <br /> Lodi, Ccijifoniia 9524,0 <br /> -'TYPE-OT WORK (Clieck) :m NEW'WELI:--/ _% "D-EI'EN / /IRECONDITION' r7—DESTRUCTION..-/--7." <br /> PUMP INSTALLATION/ / PUMP REPAIR PUMP REPLACEMENT /? - <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY T <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 \Q <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'ProEection - Rotary --� - . Type�-ofrGrout�---- <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: /Mate Work Done A� a Z6 h�P t4ee t4 <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 GROUT AND A FINAL INSPECT N. <br /> SIGNED TITLE fl S� Joaquin PuFnp Co. <br />�. <br /> DRAW PET PLAN 'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY Lodi, California 95240 <br /> PHASE I � w. . 1' � <br /> APPLICATION ACCEPTED BY DATE O <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE J!2/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY TE <br />` 3/76 2M <br /> E H 1426 Rev. 1-74 <br />