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SAN J'OAQUIN LOCAL HEALTH DISTRICT /p_i.s✓-7 <br /> FOR.-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Zip <br /> THIST.�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued' _ <br /> � /h oz7-7s <br /> . (Complete in Triplicate) <br /> Application ie 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 inade in compliance with San Joaquin <br /> : County Ordinance No. 1862 and the Rules andRegulatio s of the San Joaquin Local Health District. <br /> .y � r <br /> JOB+ ADDRESS/LOCATION��n7�4 , . -�z. G N �r.1y Z drY LJ�-S� CENSUS TRACT <br /> Own'er's Name <br /> Phone , <br /> Address D x p ,q C>S ?Y070 city. <br /> 4 1on urffump o. y , <br /> Contractor's Name Ss4A �`Q�J�/� � f Son Joaquin Sulphor Co.) License # . . . . PhoneJ!`��(3 p7 21 <br /> TYPE OF WORKCheck).,. L <br /> ( NEW WEL /? DEEPEN 17 RECONDITION /_7 DESTR TI-ON /7 <br /> PUMP INSTALLATIONf�7 PUMP REPAIR /77 PUMP REPLACEMENT <br /> 1 _ <br /> Other <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> p SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITOTHER <br /> !! PROPERTY LINE - PRIVATE DOMESTIC WELL-' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> -j Cable Tool Dia. of Well Excavation . <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> I Irrigation I Gravel. Pack Depth of Grout Seal <br /> =" Cathodic Protection- —4- Rotary- Type of Grout <br /> Disposal Other Other In€ormation ' ' <br /> !b Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: D ... <br /> Contractor <br /> Type of Pump �-�- H.P. <br /> PUMP, REPLACEMENT: State Work Done <br /> I' <br /> [1ME.:REPAIR: ;,.,,_/r,/_S.ta:te�Wo.rk Done . <br /> DESTRUCTION OF WELL: Well Diameter 4 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 <br /> my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL'zDRILLERS REPORT of the well and notify them before putting the.-wellin use.... The above <br /> info"rmation is true to-the-beet-of my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI G AN FINAL INSPECTION. <br /> SIGNED ' TITLE Sof? loaqui Pump Co. <br /> �` n� a9uin Sulphur Covj <br /> DRAW PLOT PLAN ON REVERSE SIDE 711 N. Sacramento St. <br /> E`. FOR DEPARTMENT USE ONLY Lodi, aIi arnl� <br /> PHASE I F <br /> APPLICATION' ACCEPTED BY DATE / - o <br /> ADDITIONAL COMMENTS: A <br /> if PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 1f1 - _-7. j <br />® 1r,H 1426 Rev. 1-74 ��� <br />