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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORzfOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> IM APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. p <br /> Ce T <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -7,W/77 <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 Joaquin ' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION L G CENSUS 'TRACT <br /> i� <br /> Owner's Name L -00 J Phone .33V- 1Y2,0 <br /> Address City Z-0,0/ <br /> San Joaquin Pump) Co. <br /> Contractor's Name Divisibn-of Son Joaquin Sulphur CQ,? License #,31,o37fs Phone u. S! <br /> 711 N. Sacramento St. _ <br /> `,.. <br /> Lodi, UllrvornlqVD/Nu <br /> TYOFOF WORK (Check): NEW WELL /_7 DEEPEN /% RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION I I PUMpL REPAIR / ,�/�'PfMP REPLACEMENT /_7 <br /> - r _ .. Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> !I PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 1 Industrial <br /> Cable Tool Dia. of Well Excavation _ <br /> EI Domestic/private Drilled , Dia, of Well Casing —� <br /> II Domestic/public Driven Gauge of Casing - ' <br /> 11 Irrigation Gravel Pack Deepa of Grout Seal Q <br /> !� Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> 'th Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /. / State Work Done <br /> PUMP .REPAIR-: - - /�:{�State Work Done �� C'o•%m.j 70 of <br /> �f <br /> DES-TRUCTION 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 y <br /> and1the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion 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..knowled a and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A.]~INAL INSPECTIO <br /> SIGNED TITLE San Joaquin. Purn Co, <br /> PL TPLAN ON RE ERSE.SID 'vision of San Jocqulrl 561pl Lyr Co.) <br /> I� FOR DEPARTMENT USE ONLY if mono <br /> PHASE I h Lodi,:Culifarn, 9 Z40 <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> it PHASE II GROUT INSPECTION" PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE // -y_ t <br /> E <br /> E H 1426 Rev. 1-74 - 3/76 2M <br />