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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F FOF� (��FICE :USE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> t <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. O S <br /> ` THIS PERMIT EXPIRES 13YEAR FROM DATE ISSUED Date Issued 12_.2g-. <br /> (Complete In- Triplicate) . <br /> ' Application is hereby made to the San Joaquin Local stealth Districtfar".8 permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquil <br /> ! County Ordinance No. 1862 and / Ru a an Regulations of the San Joaquin L6ca1_Health•District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name V x v�c7 I� Phone <br /> 776 6. 4-&-w � /� __ city, <br /> Address _ - <br /> Contractor's Name �ar 'oaquin:Pump CO. License # '1 7 . Phone ��-� 72 <br /> iw SAC <br /> Lodi;Cciifornia 9-2;40&:.x. .:` - <br /> TYPE OF WORK"-(Check): NEW WELL.-L T DEEPEN / ~RECONDITION -f DESTRUCTION f <br /> PUMP INSTALLATION/ UMP REPAIR'/ PUMP REPLACEMENT <br /> Other <br /> F .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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> - Industrial Cable Tool Dia. of Well.Excavation C <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 .Information - <br /> Geophysical _ Surface Seal Installed B <br /> PUMP INSTALLATION: - ' Contractor .cl ca'.ix <br /> Type .of Pump f 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 <br /> WELL DRILLERS REPORT ofthewell 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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTIK&AND A FINAL INSPECT N. <br /> SIGNED TITLE Son Joaquin Pum}r Co. <br /> DRAW PLOT PLAN ON REVERSE SIDE (Division of San Joaquin Sulphur Ce.) <br /> FO DEPARTMENT USE• ONLY Lodi, Caiifornio 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BY C DATE ' <br /> ADDITIONAL COMMENTS: JIM <br /> PHASE II GROUT INSPECTIONPHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE <br /> rw <br /> E H 1426 Rev. 1--74 -- f <br />