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SAN JOAQUIN LOCAL #T.EALTH DISTRICT <br /> F0 ZFFItE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. g5Vv <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Issue ,;2_4 _ <br /> (Complete In Triplicate) <br /> Appliceition 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 /> ,TOB ADDRESS/LOCATION se4Aj6`�- ,� CENSUS TRACT <br /> Owner's Name c ESS' i97 E G Phare $- <br /> Address /7,P�rl� ,vimCity <br /> Contractor's Name San Joaquin Pump Co. �� <br /> License #3 <br /> 6 7 Phare <br /> .. <br /> 711 N-Sacrap)gglo 1. <br /> Lodi, California 95240 <br /> TYPE OF WORK (Check): NEW WELL 17 DEEPEN 'J7 RECONDITION f7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP 'REPAIR-/� PUMP REPLACEMENT <br /> Other El- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT- OTHER <br /> PROPERTY LINE - PRIVATE PRIVATE DOMESTIC WELL`— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATIONS (� <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private r Drilled W 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 Other .Imformation <br /> Geophysical Surface Seal Installed 8 <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / State Work Done f i <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 Sara 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 GROUTING AND A FINAL INSPEC140N.. <br /> SIGNED TITLE San Joaquin Pump Co. <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Lodi, California 95240 <br /> APPLICATION ACCEPTED BY '? DATE , - Z ;V <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE A1 <br /> Er H 1426 Rev. 1-74 - 4/75 2M <br />