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.� SAN JOAQUIN LOCAL HEALTH- DISTRICT ' <br /> FOE OFFICE ME: i kl&P 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z iD /0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM 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 /> JOB ADDRESS/LOCATION Al-6 (bzouCl, 4oweie SAceA,*cy;'o &47, <br /> -ece ,ens CENSUS TRACT <br /> Owner's Name Cr) Y� 5;9 SA Jt/ _ - -- -_ Phone 369- V7,00 <br /> Address { u Q 1 (E. j7GG7-/6-2 2d City L DAO 1 <br /> 's Name San Joaquin Pump Co. f/ �/ <br /> _ r.;;g::- of sna Jor�au;n 1,O Su' <br /> Contractor phur Co.) License #, Phone <br /> 711 hl. Sacramcnto St. <br /> i <br /> Lodi, Confarnia 7 <br /> TYPE OF WORK (Check) : NEW WELL / 7 DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other / / — — <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 Drilled Dia. of Well Casing <br /> Domestic/public Driven . Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type <br /> /of Pump H.P. <br /> PUMP REPLACEMENT: it—j- State Work Done pe,;p1"a �efm�s_ .c04uAa to/A2, 14P SUA PaLp <br /> PUMP .REPAIR: / / State Work Done <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 GROUTING AND AINSP ION San Joaquin Pim CO. <br /> SIGNED TITLE 9 <br /> DRAW WT PLAN 'ON REVERSE SIDE) inslon of 50 Raquin' p ur;Co. <br /> FOR DEPARTMENT USE ONLY <br /> Set— <br /> PHASE I Lodi, California 95240 <br /> APPLICATION ACCEPTED BYi` DATE 2 ? <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY IL/ DATE 7 <br /> E H 1426 Rev. 1'74 <br /> 3/76 2M <br />