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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR;QFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. i <br /> Telephone: -{209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP ,PERMIT Permit No.z <br /> THIS PERMIT:EXPIRES -1 YEAR 'FROM DATE`ISSUED✓ F .Date Issued -7 <br /> (Complete In Triplicate) <br /> Application is hereby m6de' t6 the San Joaquin Local Health Distiict,.for a pe:rmit.. to construct <br /> and/or install the work herein described. This application ie,me.de,.in compliance with 'San J'oaquini <br /> X <br /> County Ordinance No. 1'862 And the, Rules' and Regulations of the San I -Joaquin, Local Health District. <br /> JOB ADDRESS/LOCATION uArs J-_a_F TELa,G:uTtr� -�.� CENSUS. TRACT <br /> Owner's' Name i= ` 12124,Q-'"A"t/ Phone <br /> _ _ . ^ CitycMQAdiress 1� QGIJOS T GJc!T. <br /> �w <br /> : San Joaquin Pump Co. <br /> Contractorrs Name .-*4DE,'c;nnV snn JQagh1_5.Ubhjr_Co,j„ �. License # 3/6 37 'Phone V71 <br /> -11 N._Sacramento St. <br /> Lodi, Colifarnia 95240., <br /> TYPE OF WORK-(Meek) : NEW WELL -/ j DEEPEN ,j%.W RECONDITION /_� DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR-/ PUMP REPLACEMENT <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 t_ _ CONSTRUCTION SPECIFICATIONS p <br /> :. Industrial Cable Tool Dia. 'af Well Excavation <br /> Domestic/private =� Drilled 5 =Dia.. of Well Casing <br /> Domestic/public .w •� Driven A=• ,Gauge of Casing t, ; <br /> Irrigation + Gravel Pack j Depth of Grout Seal, <br /> i,: S <br /> ,,Cathodic Protection Rotary r Type 'of. Grout ' <br /> .Disposal Other . Other Information,` ' <br /> Geophysical Surface Seal 'Instilled By: <br /> PUMP INSTALLATION: Contractor r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Mate Work Dome .r JIJI .3A60 _51/J <br />' PUMP '.REPAIR: / / State Work Done ` <br /> DESTRUCTION OF WELL: Vell Diameter Approximate Depth <br /> m <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 anew well, I will furnish the San Joaquin Local'Health District <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 I PECTION. San Joaquin Pump Co. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE of a. <br /> ` <br /> DE ARTWNT USE ONLY Lodi, California 95240 <br /> PHASE I �" - ` I <br /> APPLICATION ACCEP BY r! r9 �/V DATE S 76 <br /> ADDITIONAL COMMENTS <br /> k .PHASE II GROUT : NSPECTION• PHASE III,FINAL .YNSPECTION <br /> INSPECTION'BY DATE _ -_ INSPECTION. BY -�. DATE JI X6-•;76 <br /> 19 H 1426 -Rev. 1-74 VZ5 2M <br />