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j SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> POP OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> y Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No."77�OS-2-')0 <br /> tl. <br /> ' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> q (Complete In Triplicate) <br /> Application is hereby made: to the San Joaquin Local Health District for a permit to construct <br /> nd/or install the work herein described. This application is made in compliance with San Joaquin <br /> �ounty Ordinance No. 1862 and the Rules and Regulations of the, San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Xq M lt2 N4 w aow2+o Gr; ,e,2 6N /Jov24att _ CENSUS TRACT <br /> Ler's Name F2 t O s u Y n e 3 ra Phone <br /> g <br /> ddress i ct $ rt�l n9 . �e v R.,eo s 2� City v tJ i <br /> - <br /> (ontractor's Name San 900quin Pump Co. License Q&IL8 Phone �1 <br /> (p;vision of Son Joaquin <br /> YPE OF WORK (Check) -. W� jcE6iiTI�L'BEEPEN / / RECONDITION / / DESTRUCTION /-J <br /> PUMP INSTALLATION /c PUMP REPAIR'/ / PUMP REPLACEMENT / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> ' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL— PUBLIC DOMESTIC WELL — <br /> INTENDED USE ., TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of,Well Excavation <br /> Domestic/pfivate Drilled Dia. of FJell Casing <br /> Domestic/public Driven 0,dauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> ' Cathodic Protection Rotary Type of Grout <br /> Disposal . -`- -\ } Other„ Other Information <br /> Geophysical Surface Seal Installed By: <br /> fNNN! Au rti' - <br /> PUMP INSTALLATION: Contractor <br /> CO <br /> �,.,, <br /> Type of Pump -7-" 'e.B+-✓G H,P. , io <br /> PUMP CEMENT / / <br /> _ C <br /> ' R° / / ( State Work Done <br /> PUMP .REPAIR, <br /> State Work Done <br /> ' <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <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 my work on a new well, I will furnish the San Joaquin Local Health District t <br /> ' WELL DRILLERS REPORT of the well and notify them before putting the .well in use. The above <br /> information is true to the'rbest of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN (NAL INSPECTION. San 3o0quin Panep Co. <br /> SIGNED TITLE a ; <br /> ' DRAW T PLAN 0,• IiE FRSE SID <br /> FOR DEPARTMENT USE ONLY Lodi, Coiifornia 952440 <br /> PHASE I y/ DATE P-5?- '72 <br /> ' APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY f� DATE <br /> 11 3/76 2M <br /> E H 1426 Rev. 1-74 <br />