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_ 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: <br /> THIS PERMIT EXPIRES I. YEAR FROM DATE ISSUED Date Issued ,3-_2.1--'A6 <br /> (Complete In Triplicate) <br /> Application is hereby-made' tolthe 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 Ithe Rules and Regulations of the San Joaquin Local Health District. <br /> Af&x_7-a Se/�c' o#,Ce_2 -e4 Rd �XT�•e�.ia.f1� �SF max+/ i <br /> JOB ADDRESS/LOCATION IA1 Ff elCENSUS TRACT <br /> Owner's Name 'e'd c z:q-) Phone <br /> C/46+a O <br /> Address 2Cit770 G 1A9Z7Z_e10- <br /> � . �r' Y <br /> Contractor's Name Son .�o®ql3`` Pump Co. License 41 Phone 6��'K7f <br /> ... Lodi, Callifornip 25240 _ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /� DESTRUCTION /7 <br /> PUMP INSTALLATION /F, �PUMP REPAIR / / PUMP REPLACEMENT / <br /> 0ther — <br /> i4 <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES PIT PRIVY <br /> SEWAGE,,.DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER \� <br /> INTENDED USE TYPE OF. WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial -- .,,4.w -i• Cable Tool -Dia. of Well Excavation <br /> Domestic/private G Drilled Dia. of Well Casing <br /> Domestic/public* Driven Gauge of Casing - � <br /> Irrigation T, -Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> f 1 <br /> PUMP INSTALLATION: Contr lctor S .o p A!g u t.J cd k H.c_La Co <br /> Type of Pump u f�H .P H.P. Z - <br /> PUMP REPLACEMENT: State Work Done V °' <br /> PUMP REPAIR: / / State Work Done <br /> �. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t 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 workfon 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 west of my knowledge and belief. <br /> Son Jcaq;�€n €u p Co. <br /> SIGNED =( TITLE Mivosion of an 1a <br /> (DRAW PLOT PLAN ON REVERSE SIDE 711 N. Sacrament <br /> j FOR DEPARTMENT USE ONLY Lodi, California 55240 <br /> PHASE I I DATE <br /> APPLICATION ACCEPTED BY <br /> i ADDITIONAL COMMENTS: i <br /> PHASE II .GROUT INSPECT ON PHASE III FI AL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE C+ "�'( <br /> } CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 7172 1M <br /> 1426 <br />