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FOTO;OFFI� C�SE; <br /> 0,(' SAN JOAQUIN LOCAL HEALTH DISTRICT y <br /> t 1601 E. Hazelton Ave. , `Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION-FOR WELL CONSTRUCTION OR PUMP PERMIT Perm <br /> _ •. it No. .. � <br /> THIS PERMIT EXPIRES l __AR. FROM'DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) <br /> Applic�►tion is made to the San Joaquin Local Health.Diatrict for a prini't to con <br /> and/or ln� all the work herein described. This application ie .:made in compliance with San Jt <br /> f County Ordinance Na. 1862 and the Rules: and gulations of the San Joaquin' Local Hea ' District. <br /> 1 nth District. <br /> JOB ADDRESS/LOCATION �- c� <br /> Owner -- .. . � • <br /> 's Name -� l S G W` f <br /> _ Phone <br /> Address / /�/ ��- .t1•�� E,tJ7" ------------- <br /> eecl, _ • , - .. <br /> city C:o,o/ <br /> Contractor's Name Soar Joaquin Pump Co. y <br /> an oaqum u, : Ce,) License <br /> f TYPE OF WORK (Check): p <br /> V.�� •� •V <br /> ( k}• NEW WELL / DEEPEN I`T RECONDITIONDESTRUCTION /_7j_ <br /> PUMP INSTALLATION/ / PUMP REPAIR- pUMP REPLACEMENT <br /> v other L/:7_ /7 <br /> DISTANCE TO NEAREST: SEPTIC <br /> SEWER LINES P11 PRIVY <br /> - SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE�PIT <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL�� <br /> INTENDED USE TYPE OF WELL \ <br /> Industrial .. r. III. CONSTRUCTION SPECIFICATIONS <br /> Domestic Cable Tool Dia. Ofwell Excavation \ <br /> (private Drilled <br /> Domestic/public-- .+, �I Dia. of Well Casing (A <br /> Irrigation - — __Gauge of-Groin E <br /> t Gravel Pack � Depth of GroutgSeal \) <br /> Cathodic Protection Rotary Type of Grout <br /> —Disposal - -�' <br /> Other , Other Information <br /> Geophysical. ��-: - _ O .� <br /> `y ,�•. `,• ,. -?' .. `= Surface Seal Installed 'B <br /> PUMP INSTALLATION. <br /> . Contractor <br /> Type of- pump <br /> H.P. <br /> PUMP REPLACEMENT: / '/ Ste to Work Done — �- <br /> PUMP '.REPAIR: <br /> 9L __State Work Done <br /> .� X4 <br /> R1;STRUCTION OF WELL: Well. Di meter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with alI laws and regulations of the San Joaquin Local Health <br /> and the State of California pertaining to or regulating well'•construction. District <br /> after completion of my work on }a new well, I will furnish the San Joaquin LocalhHn FIFTEEN DAYS <br /> Health <br /> WELL DRILLERS REPORT of the well and notify them before putting. the..well. in.use-...EThe aboverict a ' <br /> Lnformation is true to-the.best-of my, knowledge and belief, I WILL r <br />'RIOR TO GROUTING AND A FINAL IN PEGTION, CALL FOR A GROUT INSPECTION <br /> iIGNED <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSESIDE <br />'RASE I FOR DEPARTMENT USE ONLY. 71 1' 1.!, . <br /> Socramento St. <br />]PP ICATION ACCEPTED BY �j Lodi, CQt�. <br /> �• fo.rnia 9 2�. <br /> ADDITIONAL COMMENTS: DATE ; o t o . <br /> PHASE II GROUT INSPECTION A <br /> NSPECTION BY DATE PHASE III FINAL INSPECTION <br /> INSPECTION .BY DATE <br /> E H -1426 -Rev. 1-74 <br />