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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 /> APP "ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZ-/4juP <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2-:2/S-7 <br /> (Complete In Triplicate) <br /> " Application is. hereby made to the San Joaquin Local Health District for a permit to construct <br /> I <br /> � and/or install the work herein described. This application is made 'in .compliance with San Joaquin <br /> ' County OrdinanceyNo. 1862' azd the' Rules and Regulations of the San Joaquin- Local Health District. <br /> JOB ADDRESS/LOCATION Sou7N Sivc DF fC67-72�E197Ac1 <br /> ` zmde z�-*,5'j o F NWe-9 CENSUS TRACT <br /> owner's Name f *��. S !Kc) 0 t3 Phone <br /> 3G - zz z.,?-- <br /> �L% City d Q/ <br /> Address (0 p � <br /> San J86gain Pump Co. License #31U3 7op'Phone 6y_j4z7/ <br /> r Contractors Name fn: ic;ne"�F C n I nr�is 1,0.61g Cn l <br /> k acrampnto 5t. <br /> t _ �Ladi Galif�rraia-9 Z; �J �.: — <br /> �TYPE OF WORK (Check) : NEW WELL'/_/ DEEPEN"/ /""RECONDITION / / DESTRUCTION f-7 ' <br /> PUMP INSTALLATION /Df UMP REPAIR / / PUMP REPLACEMENT /� } <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT .PRIVY <br /> SEWAGE DISPOSAL FIELD �& CESSPOOL/SEEPAGE PIT OTHER {J <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 a <br /> I Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic_P.ra_tection Rotary—_ x F_- Type_of Grout. <br /> Disposal It, �Other Other Information <br /> Geophysical 11A Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _ �A-y JO'r-1 0 g t.0 /961 (? <br /> Type of Pump , ,i 'a G X41� H.P. /S <br /> PUMP REPLACEMENT: / / ; State Work Done <br /> k PUMP .REPAIR: f / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter F Approximate Depth <br /> Describe Material and Procedure r <br /> F1 <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 'con.struction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, ,I will furnish the San Joaquin Local Health District E <br /> WELL DRILLERS REPORT of the well and notify them before putting the .well in use. The above <br /> information is true to thebest o£- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ° ` TITLE San Joaquin POMP Co. <br /> i'L T PLAN 'ON RE FRSE SIDE) �vrs�on of Sah' oflquin '[phut 6.) I' <br /> FOR DEPARTMENT USE ONLY 9524Q/ <br /> 5 Q <br /> _ � Lodi, California¢a.rniq �����. <br /> PHASE I <br /> APPLICATION ACCEFTED BY DATE IS <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> E 9 1426 Rev. 1-74 <br />