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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFx:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,5�' <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 Mules and Regulations of the San Joaquin Local Health District. <br /> Com' <br /> JOB ADDRESSAOCATION N.ff. Corner ofT ear & bower Sacramento-Rd CENSUS TRACT <br /> Owner's Name B. A. TO,� FRUIT CO. <br /> Phone , 369.5165 <br /> Address 693 $. TIIRNM RD LDDI <br /> fan oagrain r�i-��pCo. d City <br /> Contractor's Name (Division of Son Joaquin Sulphur Co,} <br /> License Phone 369-8471 <br /> _ : <br /> TYPE OF WORK (Check): NSW-;WELT, '/� `"DEEPEN-'-/_�'�_RECONDITfiON�-/_�F DESTRUGTION�f_�f ._" <br /> PUMP INSTALLATION / PUMP REPAIR/? PUMP REPLACEMENT <br /> Other Ll <br /> DISTANCE TO NEAREST: ' SEPTIC TANK SEWER LINES_ ."•PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE .- PRIVATE DOMESTIC. WELL CaPUBLIC. DOMESTIC WELL <br /> INTENDED USE � TYPE OF WELL � CONSTRUCTION SPECIFICATIONS <br /> Indus trial— ­ -�_.� ble. �ovl., _ Dia. of Wel]. Excavation fi j <br /> Domestic/private Drilled Dia of Well Casing <br /> Domestic/public Driven Gauge of Casing ; <br /> Irrigation Graved. Pack Depth of Grout Seal � <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Otlier Information <br /> ' Geophysical <br /> Surface Seal Installed B t _ <br /> PUMP INSTALLATION: Contractor <br /> Type, .of Pump H.P. <br /> PUMP REPLACEMENT: <br /> . XT State Work Done -Reglace 2;.HP Turbine with 5 HF Submergible Pumps � <br /> pUMr' '.REPAIR: k <br /> / / State Work Done <br /> - w .....'. -; <br /> IES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> s <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Ind 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 's i <br /> JELL DRILLERS REPORT of the well and notify them before putting. the..well. in•use.... The above <br /> Lnformation is true to the,best of my knowledge and belief. I WILL CALL FOR A •GROUT INSPECTION <br />'RIOR-TO GROUTING AND A FINAL INSP CT10N. ' <br />;IGNED r f TITLE $an Joaquin Pump Co. <br /> (DRAW PLOT PLAN ON REVERSE ID 'Slou of San ai SIDE 500E. Kettlem <br /> gn <br /> FOR DEPARTMENT USE ONLY Lodi, California 95240 <br />'RASE I } <br /> XP� LICATION ACCEPTED BY DATE 717J <br />►DDITIONAL COMMENTS: <br /> PHASE II G UT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECI'ION BY:: INSPECTION BY DATE <br /> E H 1426 Rev-1-74 .17c qu <br />