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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 ►. <br /> APPLICATION FOR WELL CONSTRUCTION OR-PUMP PERMIT Permit No. ZLIP J•a <br /> THIS PERMIT. EXPIRES 1.YEAR FROM DATE, ISSUED'� Date Issued <br /> (Complete In Triplicate) it? -3;� <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 .complianct with San'Joaquin <br /> County'Ordinarice No. 1862 and the Rules and Regulations of the San -.Joaquin Local Health District. <br /> Js-CtcZ�_•.:-,�.-_`F-fv�iJvE- �^��04 Y,a�nS ,c�,zr.v aF N+9�.uayG,r✓.v� — G�ss'r s.o�` - V � <br /> JOB ADDRESS/LOCAT ON CENSUS TRACT <br /> 361 70.x,3 <br /> Owner's Name C E /Gf✓i i.F- Phone 136 <br /> l <br /> +re.U` City LGfJ/ h <br /> Address 1197 /UC,2yW eow <br /> Contractor's Name son .,Oa Uin Pump Co. License 4� b 7 Phone7jG - 7 <br /> (Division of San Joaquin Sulphur Co.) E <br /> i <br /> TYPE OF WORK (Check) : NE4 fWEL'LC'_` / "DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT i <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool + . Dia, of Well Excavation _ <br /> Domestic/private F Drilled Dia, of Well Casing <br /> :Domestic/public Driven Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout Seal <br /> DCathodic Protection Rotary Type of Grout _ <br /> isgo- _. _..w w_ _ .._ _ w <br /> -� sal. Other Other Information` , <br /> Geophysical i Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /-'k-'s-,tate Work. Done Oyu fU l P .�LlbI�iP�2S143 e <br /> f ' 3 <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 we11 '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 andnotify 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 GROUTING AND A FINAL INSPECTION,. <br /> SIGNED �� TITLE _ Sol' 300al'i -- Co. T.Z 1 <br /> D W PLOT PLAN ON RE ERSE SIDE) Divisron f fi �` f^ a !' <br /> t 4 FOR DEPARTMENT USE ONLY 73-1-N, t <br /> PHASE I Lodi, Ct! fam94&�� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 -- <br />