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i <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT I, <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> !i <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-2--i'li <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) k <br /> Application is hereby made to the San Joaquin Local Health Distmade infor <br /> compliancetyrithconstruct. <br /> San Joaquin <br /> and/or install the work.herein described. This application <br /> and Regulations of the San 'Joaquin Local Health District. <br /> County Ordinance No. 1862 and the Rules <br /> JOB ADDRESS/LOCATION r� V F ZCENSUS TRACT <br /> Phone <br /> Owners Name <br /> City <br /> Address <br /> San Joaquin Pump Co. License # Phone36 71 <br /> Contractor's Name <br /> t' <br /> Lodi, California 95240 _ <br /> TYPE OF WORK (Check) : NEW WELL L_1 DEEPEN " / RECONDITION /� DESTRUCTION /_7 <br /> PUMP INSTALLATION � RP�.,REPAIR / / PUMP — <br /> k <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC ,TANK SEWER LINES PIT PRIVY O <br /> i <br /> SEWAGE-DISPOSAL FIELD"•+ r" CESSPOOL/SEEPAGE PIT OTHER -4 <br /> PROFERTY``LINEPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> _ CONSTRUCTION <br /> Industrial Cable Tool Dia--., of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> �^ Domestic/public <br /> Driven Gauge of Casing <br /> Irrigation -Gravel Pack Depth of Grout Seal <br /> Rotary Type- of Grout <br /> Cathodic Protection >� Other Information " <br /> Other . <br /> Disposal �r. a <br /> "-� - ,"._.�. � .a ,r_..�. :.,Surf.ace _Sea1..Installed B <br /> j _Geophysical ....... ---� _ <br /> PUMP INSTALLATION: Contractors v� <br /> H.F. <br /> Type of Pump Q �' <br /> z_ <br /> 0. LGfT�a <br /> PUMP REPLACEMENT. State Work Done <br /> PUMP .REPAIR: / / State Work Done - <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> ocedure <br /> - Describe-.Material and Pr ' <br /> I hereby agree to comply with all laws odarerela ionsulating regulating <br /> San Joaquin Lo <br /> 'construction. Withino al aDistrictlth <br /> FIFTEEN DAYS <br /> and the State of California pertaining g <br /> ( after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> I 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 GROUTIN D A FT INSPECTION. TITLE San Joaquin Pump Co, <br /> SIGNED E .0 x�uen Sulphur o.) <br /> G (DRAW PL T FLAN 'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY Lodi, California 95240 <br /> � n <br /> PHASE I - <br /> DATE '7'13 <br /> APPLICATION ACCEPTED BY . <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE / n `7 7 <br /> INSPECTION BY DATE <br /> 3/76 2M <br /> l F H 1426 Rev. 1-74 <br />