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1 ,. <br /> n �? SAN JOAQUIN LOCAL HEALTH DISTRICT n , <br /> FOE �fl 1601 E. Hazelton Ave. , Stockton, Calif. <br /> OFFICE USE: <br /> ✓ i Telephone: (209) 466-6781 <br /> Permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ----- ^ <br /> 'THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED <br /> Date Issued _2: <br /> I (Complete In Triplicate) mit <br /> a per <br /> Application is hereby made tolthe San Joaquin Locallicalth strict for <br /> inrco plzancetwithnSanuJoaquin <br /> and/or install the. work herein described. This app <br /> County Ordinance No: 1862 and the Rules and Regulations of the San Joaquin Local Health District. , <br /> cis♦ D F Goy a r� <br /> cR,e;4- Cva op end i�aa t X20 CENSUS TRACT - <br /> ,TOB ADDRESS/LOCATION <br /> .v S Capt izg� Phone 361 <br /> -Jo v(- <br /> Owner s Name � 1:1ti)� ~ l GJ[ <br /> City L a 1 <br /> Address l <br /> License � Phone361 l <br /> Contractor's Name pts Pum-D <br /> TYPE OF WORK (Check) : NEW WELL/ I DEEPEN/ / RECONDITION I P DESTRUCTIONREPLACEMENT7/,T <br /> PUMP INSTALLATION /PUMP REPAIR I I <br /> Other / / <br /> DISTANCE :TO NEAREST: SEPTIC ,TANK SEWER LINES PIT PRIVY <br /> SEWAGE�DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - PRIVATE DOMESTIC w'ELI CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable Toa1 Dia.� of,Well Excavation <br /> Drilled Dia. of .- Casing <br /> Domestic/privateDriven Gauge- <br /> Irrigation <br /> Casing - <br /> D ome s tic-/-pub li c <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Te of Grout <br /> Cathodic Protection Rotary Other Information <br /> Disposal Other <br /> _ Surface Seal InstalledhB <br /> Geophysical <br /> PUMP INSTALLATION: Contractor <br /> H.P <br /> . . <br /> Type of Pumpu tin 2 s t L y <br /> s <br /> PUNK' REPLACEMENT: / / 'State Work Done <br /> n <br /> PUMP�:REP.AIR:. _ = / Sate-..Work-Done - <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Welij Diameter <br /> Describe Material and Procedure <br /> �.. <br /> I hereby agree to comply with all law s dregulations <br /> xegulating welleconstruction.f thSan JoauinLoWithinaFIFTEENtrict DAYS <br /> and the State of Californa�a7pertaaWing toor <br /> t after completion of my wort/ on a new well, I will furnish the San Joaquin Local Health Distract r <br /> above <br /> WELL DRILLERS REPORT of the well fnm notify <br /> knowledgethem <br /> andbefore <br /> beliefputting <br /> WILL CALL FOR A GROUTeINSPECTION <br /> information is true to the best a y <br /> PRIOR TO GROUTING AND A F NSPECTION TITLE Son ,Joaquin pump Co. <br /> SIGNED p ur o. <br /> (DRAW T PLAN ON REVERSE SIDE , <br /> FOR DEPARTMENT USE ONLY Lodi, California 95240 <br /> 1 <br /> . PHASE I I DATE <br /> APPLICATION. ACCEPTED BY <br /> } ADDITIONAL COMMENTS: PHASE TII/FINAL INSPECTI <br /> PHASE II GROUT INSPECTION INSPECTION BY <br /> INSPECTION BY DATE <br /> b/77 _ 2M <br /> v N 1A9A Rev. - Y-74 <br />