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f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i FO&!OFFICE USE: 1601 E: Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,Z5-- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued5 <br /> Application is hereby made to the SancJo <br /> Complete <br /> uin Lodal Health District fo <br /> and/or install the work herein described. This application is made inrcomplianceCwithnSanuJoaqufa <br /> ct <br /> County Ordinance No. 1$G2 and the Rules and Regulations of 'the San Joaquin Local Health District. <br /> s <br /> /3-302— <br /> .-JOBADDRESS/LOCATION r CENSUS TRACT <br /> x <br /> Owner's Name SIWOL I- ra Phone }/d V V 2— <br /> Address F ! City <br /> San Joaquin Pump <br /> Contractor's Name ' vision'of San Joaquin Sulphur Co.) <br /> �s 500 E'. KettlemaLicense n Phone <br /> i, o i orn�a <br /> _ 'YP8 OF WORK (Check): .NEW WELL/? DEEPEN'/7 -RECONDITION /_7 <br /> DESTRUCTION- <br /> PUMP INSTALLATION L_7PUMP REPAIR /_7 PUMP REPLACEMENT <br /> OtherL7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL-FIELD . � CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVA DOMESTIC WELL ' PUBLIC DOM <br /> INTENDED USE E TS IC WELL <br /> )TYPE OF WELL <br /> CONSTR[1CTION SPECIFICATIONS (AIndustrial of-'Well Excavation <br /> Domestic/private Drilled .` Dia. of Well Casing p <br /> Domestic/public . Driven <br /> Irrigation Gauge of Casing <br /> --- R y , iy �t Gravel Pack' Depth of Grout Seal <br /> Cathodic'Protection i ltotary` Type of Grout <br /> ' <br /> I -Disposal Disposal .: Other s' Other Information <br /> Geophysical .f _ . <br /> 11Lr Surf ace Seal Installed B <br /> Rr �4 4 S <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> A.P. <br /> PUMP. REPLACEMENT: R'{I��4�e 7e i Pump !u. �L�; ,S-�yP 676 <br /> t State Work Done S ! d a 676(,/,o <br /> r a��=q <br /> PUMP :REPAIR: /_7 State Work Done <br /> SES;TRUCTION OF WELL: WeXl Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws -and regulations of the San Joaquin Local, Health District <br /> and the State of' Cali-fornia 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 /> i information is true to the best of my.knowledge and"belief. I WILL CALL FORA-GROUT INSPECTION <br /> PRIOR TO GRO14MG AND A FINAL INSPE ION. <br /> SIGNED 1 San Joaquin Pump Co. <br /> TITLE D1 Islon of San Jao uin Sulphur Co.) <br /> (DRAW PLOT PLAN ON REVERSE SIDE -.i 500 E. Kettle man <br /> • 7 O C <br /> -'WOR DEPARTMENT USE ONLY Lodi, California 95240 <br /> PHASE_ <br /> HA- ASEEII <br /> APPLICATION ACCEPTED BY I <br /> ADDITIONAL COMMENTS; DATE ! s <br /> PHASE II GOUT INSPECTION <br /> INSPECTION BY PHASE III/FINAL INSPECTION <br /> DATE INSPECTION BY DATE � ' I / <br /> E H 1426 'Rev. 1-74 <br /> ¢ �` <br />