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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE; 1601 E. Hazelton Ave.; Stockton, Calif. <br /> Telephone: (209) 466-6781 ; <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7 <br /> 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM'DATE'ISSL`IED Date' Issued. <br /> (Complete In Triplicate) t q_0-ve-e3 <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 applicatioa' is'made In-compliance with"San Joaquin. <br /> jCount y 'prdinance No. 1862 �ind the Rules and Regulations of the San -Jdaquiri Local''Health District. <br /> G€W.IT�� _✓�" ''. '�D2.T/Y SnOE off' L�3e�Tj•. �„qfl -....���� /(�, •. . . <br /> JOB ADDRESS/LOCATI #c Tw.6 ,qv r CBNSiJS' TRACT <br /> Owner l it ftme cr , Phone <br /> Address �i , <br /> .. �•, / 4o� <br /> r l p 9 ,., ---• - City 5/3,ri.�r6�� �',G'itrd`,S <br /> Contractor's Name San Joaquin•Pump Co. <br /> so, lang-fin q.1ahuc r-6-1 License # =37 Phone 7 <br /> 711 mento St. <br /> E; Lodi, California 95240 - <br /> TYPE OF-WORK (Check)t NEW WELL -L-7 DEEPEN -/f RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION L7 PUMP .REPAIR-�UMP REPLACEMENT—,L7 <br /> Other .!_] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY '1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT. OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WEI.I." PUBLIC_k0MSTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS1 <br /> Industrial Cable Tool Dia. of Well Excavation ' <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Drives Gauge 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 'B : <br /> PUMP INSTALLA,TIONt Contractor <br /> Type of Puucp <br /> R.P. <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PUMP 'REPAIR; . - Mate Work Done Cyr7 j C014W ) 15jV' <br /> DESTRUCTION OF WELL: . Well Diameter Approximate Depth <br /> Describe Material, and Procedure <br /> I I hereby.,agree to comply la <br /> 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' conpletion of my work on anew 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. TWILL CALL FOR A'GROUT INSPECTION <br /> PRIOR TO •GROUTING 'AND A FINAL INSP ION. <br /> SIGNED ( San Joaquin Pump Co. <br /> TITLEliGnhfRnQnmkl <br /> DRAW PLOT PLAN ON REVERSE SIDE I <br /> PHASE I F0 DEPARTMENT USS_ONLY Lodi, California 95240 <br /> • APPLICATION ACCEPTED HY DATE' '-- -G.: _ <br /> ADDITIONAL COMMENTSt <br /> PHASE II GROUT INSPECTION PHASE XXVFINAL INSPBCTI i <br /> INSPECTION BY DATE �— INSPECTION BY DATE o <br /> E H 14'26 Regi. '1-74 r. h/75' 2M <br />