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SA^1 JvP_OEIbF LGCAL iEALTII DISTFICT <br /> �OF OFFICE USE: f 1501 E. Hazai.can Ace„ Stockton, Calif. <br /> TelephI :;T;e: (209) '166-6 781 <br /> APPLICP_TION FOR FLI. CONSTkUCTION OR PUMP iPFRMIT Permit Na. <br /> THIS PERMIT FXPI.RES 1 `_'FAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <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 Joaqui <br /> County Ordinance No. 1862 and the rRules and Regulations of the San Joaquin Local Health District. <br /> - JOB ADDRESS/LOCATION ,le 1115'f c' %f t�TcJ� - '[� }lf�i' 1C' 2dSU5 TRACT <br /> C4 <br /> Owner's Name knxiPhone <br /> Address zol CI.P�L�ti� /:�� City <br /> San Joaquin Pomp fir. �� <br /> Contractor's Name Diriston cf Sar.3ea uin �i ' •c� License # Phone <br /> 711 N. Socramz�=.f-, ±. <br /> Lodi,C0f,,, j ., <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN_/ / RECONDITION /_/ DESTRUCTION /� <br /> PUMP INSTALLATION /b/'PUMP REPAIR / / PUMP REREPLACEMENT -7 <br /> AL <br /> Other <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 C <br /> INTENDED USE TYPE OF WELL CON TRUCTION SPECIFICATIONS L <br /> Industrial Cable Tool Dia. of Well Excavation <br /> d. Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing G <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout 1 <br /> J Disposal Other Other Information' <br /> Geophysical Surface Seal. Installed By: l <br /> PUMP INSTALLATION: Contractor <br /> ' Type of Pump vH.P. 4!C) <br /> PUMP REPLACEMENT: / / State Work Done <br /> � r <br /> k PUMP .REPAIR: I I State Work Dane <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 putting the well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT D A FINAL INSPECT <br /> SIGNED TITLE u09gf�Pffi F�iCtE Co. <br /> :(DRAW PVOT PLAN ON REVERSE SIDE ivision of 50"Onquin 5u1phur'C0 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 V f1 APPLICATION ACCEPTED BY t� _ DATE { "' <br /> f ADDITIONAL COMMENTS: <br /> MPHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTIONBY g E, ', = c'.. DATE til <br /> E H 1426 Rev. 1-74 3/76 2M <br /> i <br /> k <br /> I <br /> ti <br /> F <br />