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_ �� SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFF7:CE USE <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ 1 <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 AeUEu11 CENSUS TRACio07 �� l! <br /> Owner's Name G4j T S Phone �33rl-- 3ZS-.5— <br /> Address City [�, 7 <br /> San Joaquin Pump Co. <br /> Contractor's Name License �� 37Phone <br /> 11 N <br /> Lodi, Cohhfornia 95240 i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/� - RECONDITION %_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION/ UMP REPAIR/ / PUMP REPLACEMENT 17 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER o� <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 of Pump —. C��G � H.P. <br /> PUMA' REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-T,r�UCTION 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 GRO D A FINAL INSPECTION. <br /> SIGNED TITLE Son Joaquin Pgmp Co. <br /> DRAW PL'T PLAN ON REVERSE, SIDE) + n o no aqui n' rphgr Ca.) 3 <br /> OR DEPARTMENT USE ONLY <br /> PHASE I Lode, Colifornio 9524n <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL. COMMENTS: <br /> PHASE II GROUT INSPECTIOW PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z <br /> E H 1426 Rev. 1-74 376 2M <br />