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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave;, Stockton, Calif. b <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZ 1 gdy6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUEb Date Issued 1f_27 <br /> (Complete In Triplicate) <br /> Application is hereby made tj 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 Sari Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS- TRACT ' <br /> Owner's Name G! - - ---- � Phone <br /> �F -�2 !S Tc 4'S <br /> - i <br /> Address 4 �5 e. 2erwcr City _ G61-2 - ^� <br /> San Joaquin Pump Co. <br /> Contractor's Name of SAn laaAln Sulphur Co.) License # Z1037.k Phone �p_,fy7/ <br /> 711 NSacramento St. <br /> i <br /> Lodi, Califarnia 95240 _ <br /> < -TYPE-�OF-WORK ..(.Check) :,-NEW-,WELL /� .DEEPEN /—/..„RECONDITION I I; DESTRUCTION /? <br /> PUMP INSTALLATION I I PUMP. REPAIR I / PUMP REPLACEMENT %-;� °" ' <br /> Other <br /> DISTANCE TO NEAREST: SEPTICTANK SEWER LINES PIT PRIVY <br /> SEWAGE .DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY TINE - 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 1 Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation <,. ^ ,.. -Gfavel Pack Depth of Grout Seal <br /> Cathodic Protection --Rotary - 4 - Type-of -Grout - <br /> Disposal ti- 1. =. Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> `r _ J <br /> PUMP REPLACEMENT: /c./�State Work Done ,�� f��.� �'X/S f 7 - _��i fh �„_P. Sag <br /> PUMP ,REPAIR: / / State Work Done <br /> 1 <br /> r <br /> DESTRUCTION OF.WELL: Well Diameter T'"'Approximate-Deptih� ' m - "" <br /> Describe Material and Procedure 4 <br /> . s <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 wiell and notify them before putting the -well in use. The above <br /> information is true to the best of myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO NG AND A FINAI,1 INSPE ON. <br /> SIGNED r TITLE San Joaquin Purnp Co. <br /> (DRAW,PLOT PLAN 'ON REVERS E SID ivisioa a an phquin u w I+ `` <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Lodi, Ccs!=co.rnia 95250 <br /> APPLICATION ACCEPTED BY _ r - DATE 2` �-�-� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE Z <br />� E H 1426 Rev. 1-74 .. .., . <br /> 3/76 2M <br />