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o3 DATE <br />PHASE I, <br />APPLICATION ACCEPTED BY <br />t /TIONAL COMMENTS: <br />CESSPOOL/SEEPAGE PIT OTHER <br />/ / State Work Done PUMP REPAIR: <br />4)ESTRUCTION 0;'W : Well Diameter Approximate Depth <br />TYPE OF WELL <br /> Cable Tool <br />Drilled <br /> Gravel Pack Depth of Grout Seal <br /> Rotary Type of Grout <br />Other Other Information <br />INTENDED USE <br />Industrial <br />CONSTRUCTION SPECIFICATIONS <br />Dia. of Well Excavation <br />Dia. of Well Casing <br />Driven Gauge of_Casing <br />Domestic/private <br />Domestic/public <br />Irrigation <br />Other <br />Contractor <br />Type of Pump <br />/7K7S;ate'Work Doneohii.c.e f3 sbz7f_61 a •-1,"‘ 1- Punt p 1.-0, <br />Describe Material and Procedure <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER L <br />SEWAGE DISPOSAL FIELD <br />ES PIT PRIVY <br />'PUNT INSTALLATION: <br />PUNT REPLACEMENT: <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. Son Joaquin Pump CO. <br />(Dii•:sion of Son Joaquin Suftehor Ca-) <br />SIGNED 7"e-' TITLE 711 N Snripmentn Sp <br />(DRAW PLOT PLAN ON REVERSE SIDE) <br />FOR DEPARTMENT USE ONLY <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. Hazelton Ave., Stockton, Calif. <br />Telephone: (209) 466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP FERN <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Triplicate) <br />Application is hereby made to the San Joaquin Local Health District for a <br />and/or install the work herein described. This application is made in compliance with San <br />County Ordinance No. 1862 anethe Rules and Regulations of the San Joaquin Local Health District. <br />EA S T: oF --Org rto<.) Aie, 7)4 n per r <br />JOB ADDRESS/LOCATION Kr 7-i-z6.:7/r),1.$, A/ tttc r ç, oe 0 1 T <br />(1) F LI r C. <br />City <br />License # Phone <br />Permit No. <br />Date Issued /-,,P,9--7 <br />permit to construct <br />Joaquin <br />$he&-0 CENSUS TRACT <br />Owner's Name <br />Address <br />Contractor's <br />I:: tS" it/ <br />Name Son Joaquin Pump Co. <br />...I' <br />erern,Y.Prota <br />Phone 36q- 2.7.34,1 <br />-TYPE-OF'W-0- <br />Lodi, Cclifontig15240 <br />(Check):'NEW WELL / --DEEPEN -/TT RECONDITION1 / DESTRUCTION /7 <br />PUMP INSTALLATION / /--PUMP'REPAIR / 1 --PUNT REPLACEMENT <br />Other / / <br />' 1 <br />PHASE <br />DATE <br />III/ INAL. INSPECTION <br />INSPECTION BY DATE INSPECTION BY <br />PHASE II GROUT INSPECTION <br />i <br />CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />E H 1426 7/72 IN