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Q ' <br /> 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. 7.<--,)- <br /> THIS PERMIT EXPIRES 1 YEAR FROMDATEISSUED Date Issued G —T <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constructT <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> J- .7-nA*­120 <br /> JOA ADDRESS/LOCATION `l3riwe'jAU TAHt)- T Ca LC/e/Z ftp . Lc1�s Sf4f d Z;ck-T&ve CENSUS TRACT <br /> Owner's Name f N,a e i" i k IV 2. Phone 6 <br /> Address - AlJ _ c 1c_l a�JrJ R OfA 1j city CAM7 <br /> Joaquin Pump Co. <br /> Contractor's Name San Joaquin Sulphur Co.) License # Phone <br /> 00 E. Kettleman <br /> Lodi, California <br /> TYPE OF WORK (Check) : NEW WELL/"T DEEPEN j-7 RECONDITION J7 DESTRUCTION f7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR '/ / PUMP REPLACEMENT / Z <br /> Other / / 7`� <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 Casing <br /> Domestic/public Driven Gauge of Casing <br /> g <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / 2 State Work Done g4_pJacr.vc /J- // S[c ) <br /> PUMP :REPAIR: / J 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 <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 INSPE ION. San Joaquin Pump a. <br /> SIGNED �-- TITLE mlyision of San Joaquin Sulphur C90 <br /> (DRAW PLOT PLAN ON REVERSE SI : 300 9. Kettemon <br /> FOR DEPARTMENT USE ONLY Udrj Calitornia <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE L7j <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III FINAL INSPECTION / <br /> INSPECTION By DATE INSPECTION BY DATE 31 ;tS <br /> E H 1426 Rev. 1-74 h/75 _ ' <br />