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t <br /> FOR':OFFICE USE: JOAQUIN LOCAL. HEALTH DISTRICT' <br /> 1601 S. Hazelton Ave., Stockton, Callt. <br /> Telephone: ' (209)' 465-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 `YEAS <br /> ON DATE...IS5UED <br /> Date Issued <br /> (CompleteIn Triplic <br /> Application ie hereby made tate) <br /> o the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described, - This appl,icatioit is ;made in compliance .w,ith.: SaneJoaquin <br /> County Ordinance Na. 1662 gnd the. Rules and Regulations;af, the Saar Jaaqun. Laical., .Health. District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS, TR4CT <br /> Owners Name N -: ll '1.iJ SEitJ <br /> i <br /> hone <br /> Address . <br /> - <br /> Contractor''s Name Scitf 7ooquin Pump Co. , <br /> ivision o License :31 Phone 6 "-�'ir"7 <br /> N +1Check): <br /> �t�,r1i Cfb.r ' 95240 <br /> TYPE of WORK ( _nom . <br /> DEEPEN ,/-7 RECONDITION:_...-..DESTRUCTION .f f ...... : <br /> PT1MPDSTALLATION /Lf' PUMP REPAIR-/ PUMP REPLAC <br /> EMENT17 <br /> Other, <br /> ..'j. ./ _ . <br /> DISTANCE TO NEAREST SEPTIC TANK <br /> SEWER LINES PIT PRIVY. <br /> SEWAGE :DISPOSAL FIELD <br /> _�, CESS 'DOL/SEEPAGE PIT OTHER' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL:', PUBLIC DOMESTIC WELT. <br /> INTENDED. USE TYPE OF WELL <br /> _ Indus trial ,.. : a CONSTRi3CTION.SPECIFICATIONS (n <br /> Cable Tool Dia: sof Well Excavation <br /> Domestic/pri'vate Drilled Dia. of- Well Casing,..'. \� <br /> Domestic/public 7Driven <br /> Irrigation Gauge of Casing <br /> Gravel Pack 'Depth of Grbur Seel <br /> _ Cathodic Protectionr Rotar <br /> Disposaother3 i— �. _.,Y Type,of Grout <br /> s <br /> Geophysical,.::-_ "`_ --- Other' Information <br /> I <br /> Surface Seal Installed 'B <br /> PUMP INSTALLATION: I <br /> - Contractor. : �'C1S� <br /> Type ;o€ Pump g <br /> ' S.P. <br /> PUMP REPLACEMENT <br /> State W <br /> ork Done <br /> PUMP '.REPAIR; <br /> /7 :Stn to Work Done <br /> DESTRUCTION OF WELL: Well Diameter , <br /> Describe Material..and Procedure Approximate Depth <br /> �._. <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 °con <br /> , ur <br /> struction. Within FIFTEEN DAYS <br /> after completion of my work ona new wellI will'€ nish the San Joaquin.Local Health District' a <br /> WELL DRILLERS REPORT of the Well and notify,. them before putting..the.-well is.;use... .The above <br />?RIOR To r.R is .true to the best of my..lcnowledge and belief. I WILL CALL 'FOIt A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTIO <br /> SIGNED I <br /> TITLE SdA Joaquin Pump Co: <br /> I DRAW PLOT PLAN ON REVERSE .SIDE). trjsion o ao aagwn , <br /> PHASE I . FOR DEPARTMENT USE ONLY <br /> ' Lodi, .Coiifarnia 95240 <br /> APP~' LICATIOW ACCEPTED BY r .`. <br /> ADDITIONAL COMMENTS: DATE ' Z" <br /> PHASE I f GROUT=OUT <br /> ETSPECTION BYPHASE III FINAL INSPECT ON <br /> DATE INSPECTION BY DATE tee' p <br /> ,.= <br />