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r SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> -FO—F--'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> <• -- Telephone: (209) 466-6781 <br /> AP ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7-3 a� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 7 <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 41 l/�ac,7-1v d Liwe .7,uo /�omt a., !fS 11,44ve$- 6A1 CENSUS TRACT <br /> Owner's Name '7774Z-e Phone <br /> Address / G, G/!/ City Gds/ <br /> Contractor's Name Son Joaquin Pimp .-C License # L 3 7 Phone �M '-jY 7/ <br /> ranipmtn St. <br /> La4j (•^l:fose,Ia 95240 _ i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/_/ RECONDITION /_/ DESTRUCTION /-7 <br /> AL <br /> PUMP INSTALLATION /Z-7 REPAIR / / PUMP REPLACEMENT /7 <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 Drilled Dia. of Well Casin <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal \ <br /> Cathodic Protection' Rotary Type of Grout r[� <br /> Disposal' Other Other Information 6 <br /> Geophysical Surface. Seal Installed By: . _,. • . .,_.__. <br /> PUMP INSTALLATION: Contractor ,J U� �Ultt <br /> Type of Pump I 67F H.P. o <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 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 INSPECTIO Sin Joaquin Pump Co. <br /> SIGNED - TITLE <br /> DRAW PLOT PLAN ON -- EItSE SIDE - Mpnta+ ' ". <br /> FOR DEPARTMENT USE ONLY wui, California 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BY [ �� DATE 3 -��' 72 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE l 9 <br /> E H 1426 Rev. 1-74 . <br /> 3/76 2M <br />