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c6 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <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 /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,./_/_2_76 <br /> (Complete In Triplicate) 1 <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 Rules and Regulations of the San Joaquin Local Health District. ,l <br /> .%0+-4.T4•i Srpc Ot Tu/t.vC2 2opf� ���f Inl� weST of <br /> JOB ADDRESS/LOCATION spate na 7a 2a�ta CENSUS TRACT <br /> Owner's NameImo.. l�Lc�N -- r Phone <br /> Address c E L `�,C�� i� Cit <br /> /t San Joaquin Pump Lo. Y <br /> �+ontractor's Name - _.jp <br /> ivision of San Joaquin Sulphur Co.) License irk Phone 36 <br /> 711 N. Socramer+ a <br /> Le i, Callrarn+cr { <br /> TYPE OF WORK (Check): NEW WELL FT DEEPEN f; 7' RECONDITION /_ DESTRUCTION /7 , { <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER € <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private __.- . .-- .-Drilled -- -Dia-.- of-Well -Casing--- ( + <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> k. I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done rU,l_/. , 41,77 11 Pct- tudl Co,f4,7-,,a4V <br /> ,?ES_TRUCTION OF WELL: Well Diameter Approximate Depth <br /> —� Describe Material and Procedure i <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 well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED 11 TITLE Son Joaquin Pump Co. <br /> (Division of San Joaquin Sulphur Co.) <br /> (DRAW PLOT PLAN ON -REVERSE SIDJET 711 N. Sacramento St. <br /> FOR DEPARTMENT USE ONLY Lodi, Calitornia a <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS p <br /> PHASE II GROUT INSPECTION PHAS§:;IjjjFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />