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SAN JOAQUIN',LOCAL HEALTH. DISTRICT <br /> FOR O?�710E*USE: 1601 E. Hazelton Ave. .. Stockton, Calif. <br /> Telephone;: (209) 466-6781 n <br /> APPLICATION FOR WELL,:CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES .I YEAR FROM DATE ISSUED Date Issued 7 g 1.7 7 <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 /> , <br /> JOB ADDRESS/LOCATION T —.S�r—c-- �G !/C� S�� CENSUS TRACT ' <br /> Owner's Name �� ��p. GtJ� Phone 3b,"I?— <br /> Address Z `Z-8 91 /V (Z L4,C CCA City 4.,f-,o 9 <br /> I' Contractor's Name Sao Joaquin PUMP Co. <br /> License..;#,3163 8'Phone..���� '. <br /> (Division of an 33aquin N:: <br /> Qd���Ct3�i�•�SCl �3�f!'J <br /> I` TYPE OF WORK (Check) : NEWtWELi� _/ DEEPEN/ / RECONDITION /� DESTRUCTION f� <br /> PUMP INSTALLATION / / PUMP REPAIR /PUMP REPLACEMENT /� <br /> Other '1_7 <br /> k <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 <br /> Domestic/private -x a Drilled Dia. of Well Casing . <br /> Domes:ti�_/public­ `' • .-Driven K Gauge of Casing <br /> 'Irrigation Gravel-Pack, Depth of Grout-Seal <br /> Cathodic Protection r Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical ` 1 'Surface Seal Installed BY: _ - <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT L/ Done- <br /> 4. f <br /> S Y <br /> TM _ <br /> .tea. 6 .may .�./...,..� r' .. <br /> State'Work Done- c c�1 ��cgfL!/n:t1"�`�" 9, <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> l and the State of. California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> k after completion of my work on a new well, Iwill 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 TOG DAF ALI S IO 1- <br /> SIGNED TITLE Sort Joaquin PLimp CO. <br /> RAW PT T PLAN ON RE RSE SIDEXDivision of 5an'lz6quin t4161'iur'Co.)` <br /> FOR DEPARTMENT USE ONLY acrameri o <br /> Lodi, California 96240 <br /> k PHASE T <br /> APPLICATION-ACCEPTED_BY_ -_ - .. ^`"" ` - - DATE f. <br /> ADDITIONAL COMMENTS: <br /> _PHASE_ II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 - <br />