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fSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS.-OFFICE USE: 1601 E. Hazelton Ave.,. Stockton,-,Calif. <br /> 1 <br /> 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 <br /> APplicetion is hereby made to the San(Jo Joaquin Localli;Omplete In calth District- for <br /> .& permit, to. construct <br /> and/or install the .work This application isd <br /> mae ia; comPliance with.:San Joaquir <br /> j County Ordinance No.. 1$62 'and the Rules and Regulations of the San 3oaquin. i,ocal.;Health..Dstrict. <br /> :4 �J <br /> JOB ADDRESS/LOCATION <br /> i ,. CENSUS TRACT <br /> 6. <br />' Owner's Name .' ` y : <br /> f Phone{ <br /> Address <br /> Citq <br /> ;Contractor's Name , - _ <br /> .- N License.1 , 7� <br /> TYPE OF WORK ( <br /> Check) .-' NEW WELL17 DEEPEN -/ RECONDITION f7 DESTRUCTION f_7 <br /> PUMP INSTALLATION/_ PUMP REPAIR -f PUMP REPLACEMENT <br /> k Other /_7 %7 <br /> DISTANCE TO NEAREST: SEPTIC TAMC SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT. OTHER pp ' <br /> PROPERTY LINE -- PRIVAATE ..DOMESTIC-WELT.-: ' �v <br /> INTENDED USE TYPE OF WELL PUBLIC DOMESTIC WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of W61-1zExcavation <br /> _)u' „ Domestic/private � Drilled Dia. of Will,Gasing.,. <br /> Domestic/public <br /> Irrigatiaxi Driven Gauge of Casing t, . <br /> �'"`�'" <br /> Gravel Pack` Depth of Grout Seal <br /> Cathodic Protection Rotary Type' of. Grout <br /> Disposal Other Info <br /> r Other � rmation <br /> Geophysical n .. --------�-. L i <br /> Surface -seal Trim talled 'B <br /> E <br /> PUMP INSTALLATION: ContractordiiMlo <br /> Type of Puip �. <br /> H.P. <br /> ` i <br /> PUMP REPLACEMENT: /r/ State Work Done <br /> PUMP 12EPAIRState Work �- <br /> Done j 4,HiQ./ <br /> __ . <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depthw <br /> I hereby agree to comply with all lawsjand regulatioIL <br /> ns of the San 3 1 , . <br /> and the State of California' pertainingito or .regulating well 'construction:L�WithinaFIFTEE1Q <br /> , I will f <br /> DAYS <br /> WELL DRILLERS REPORT strict <br /> after Completion of my work an a new wellurnish the San Joaqufn Local Health District a <br /> of •the well and notify them before putting.. the..well_. in.use... The above <br /> information is true to the-best-of my kriowledge_and.,belief. . I WILL CALL :FOR 'A:GROUT INSPECTION. <br /> PRIOR TO GROUT,ING''AND A FINAL INS CTION. 1 , ti <br /> SIGNED TITLE SanJoaquin Pump Co. <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR'DEPARTMENTsUS-- ONLY Lodi, Galifarnin 95240- <br /> A ICATION' ACCEPTED BY <br /> ADDITIONAL.COMMENTS: DATE <br /> PHASE II' GROUT INSPECTION PHASE III FINAL INSPECT ON , <br /> INSPECTION BY _ DATE INSPECTION BY <br /> i - DATE � l <br /> E H 1426 Rev. 1--74 <br />