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•r / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi OFFICE USE: !!!/// 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � y�a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-,2Z-24 <br /> (Complete In Triplicate) 6b9- 0_5O 03 <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. <br /> li(o°fr2r .�Le'r"aJ�'�"'�p2rN SioE of Lr4e:2rt /2oR7a� —/��++.�, <br /> JOB ADDRESS/LOCATIOEAST of SACK To 6 2o.o43 CENSUS TRACT <br /> n <br /> Owner's'Name Phone <br /> Address , Q T City S/1iuE/G �i4�6'1 <br /> San Joaquin Pump Co. 3k-?7k— %� JVW <br /> Contractor's Name (a ,,. ,, <br /> ;„,; ,c,,,, c„ier,,,, c� Phone <br /> .: License $ <br /> 7 1 N. Sacramento St. <br /> Lodi, California 95240 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN/7 RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION L7 PUMP REPAIR UMP REPLACEMENT 17 <br /> Other / 7 <br /> 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL -r PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Rt <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 /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: - State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 a <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe well in-use.. The above <br /> information is true to the-bestof. my knowledge and belief. I WILL CALL FOR AGROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSP <br /> TI <br /> ION. Son Joaquin Pump Co. <br /> ( TLE <br /> SIGNED <br /> DRAW PLOT PLAN ON REVERSE SIDE 717 N Sacramento t <br /> FO k DEPARTMENT USE ONLY Lodi, Colifwnio 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BYaDATE <br /> ')ITIONAL COMMENTS. <br /> PHASE II GROUT INSPECTION PHASE IW4FINAL INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE o <br /> E H 1426 Ren. 1-74 G/75 2M <br />