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F % 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 PUMP PERMIT Permit No. ,��"-�1�D/� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> j (Complete In Triplicate) <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 incompliance with San Joaquil <br /> Cou/,nty-,Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> { �t�tT7`L Es.f o F Nuor F9 , 5rc :cI Sd4� 4 <br /> JOB ADDRESS/LOCATION _ 7���� I e r2 r-taco-s e �v, 1-4 F-fl t,c _ CENSUS TRACT 66!- n <br /> r. Owner's Name Phone r!� r1 - -6� <br /> 1 f <br /> Address. t (. e— City `c: f -- <br /> i <br /> ka Joaquin Pump CO. <br /> Contractor's Name Dtvhlon of San Jonquin Sul hu 1 Licenbe # ' Phone <br /> E. Kettleman <br /> rode, Can arrarq — <br /> TYPE OF WORK (Check) . NEW''WELL / / DEEPEN '/? RECONDITION /? DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT <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 ..—Gauge,-of Casing <br /> Irrigation Gravel -Pack- Depth of Grout Seal <br /> Cathodic Protection, Rotary<, ,•. ' x Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed .By: _—_- <br /> { <br /> i <br /> i PUMP INSTALLATION; Contractor <br /> Typeof Pump H.P. <br /> PUMP REPLACEMENT: / jState Work Done / / _6,cralk, <br /> PUMP-REPAIR: f7 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 tle 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. I WILL CALL' FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> Son Joaquin Pump Co. <br /> ' SIGNED TITLE <br /> } (DRAWPLO PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY Lodi, California 95240 <br /> PHASE I <br /> APPLICATION_ACCEPTED BY DATE 6 . -J-' <br /> j ADDITIONAL COMMENTS_- _,,. 1 <br /> PRASE II ROUT- INSPECTION PHASE III/FM INSPECTIO <br /> INSPECTION BY INSPECTION BY DATE -,/_. <br /> E H 1426. Rev. 1-74 <br />