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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ✓ 1601 E, Hazelton Ave. , Stockton, Calif, <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR P rmit No. .773- 100 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued '7- 1-76 <br /> (Complete In Triplicate) 00 -OF0 -31 <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 /> iu t; 4-- 1;" c, o F Ta l40 * i2o Looz+ d F Cow eie� <br /> JOB ADDRESS/LOCATION P„Ey" - Soc....t,c{ 7,B wall S je_,. CENSUS TRACT <br /> . Owner's Name /_ rz o ac _L(.y[a S CBstfz�tis Phone S6� --30 V4 <br /> Address A0 & 1 N, City - 4,001 <br /> _- <br /> �p W.6 3 7g <br /> Contractor's Name Saw b 6In PUMD CO. License 1I��_ Phone36! c 7 7l <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION /-PUMP REPAIR / / PUMP REPLACEMENT f_1 <br /> Other / J <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 /> 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 ��A UO _41'10 AU*,tj2 0,0 <br /> Type of Pump -----9-W4__A4-E I �d L_L H.P. <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 thewell 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 F NSPECTION - San Joaquin Pump Co. <br /> SIGNED TITLE <br /> (DRAW T PLAN ON REVERSE SIDEjuuptur <br /> PHASE z FOR DEPARTMENT USE ONLY Lodi, California 95240 <br /> APPLICATION ACCEPTED BY A.Icd DATE -'1-9�)� <br /> ADDITIONAL COMMENTS: or <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTI <br /> INSPECTION BY DATE INSPECTION BY _ �, l � DATE Z <br /> E H 1426 Rev. - I-74 <br /> b177 _ 2M <br />