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";. ZISAN- JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&,OFFICE USE: 1�e 1601 E. Hazelton Ave'. ,:. Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ji APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> !I THIS P9 MIT EXPIRES 1 YEAR FROM DATE 'ISSUED _ , Date, Issued <br /> '3 (Complete In Triplicate) <br /> Application is hereby 'made td the San Joaquin Local Health District for apermit. to construct <br /> tend/or install the work herein described. _ This application is made in"coi'pliance with San Joaquin <br /> County Ordinaice. No. $862' and the Rules and Regulations of the San,Jbaquin,'Local Health.:Distriet. <br /> JOB ADDRESS/LOCATION Sou 7W- SiOh d Jig u6 Wr 1,5„T <br /> ,. --- __�Pz.oiu� �d ...,._...r....,___._,....,,..,,,. {'CENSUS TRACT <br /> Owner's A1ame1 , ”'""li��Dr,elC! r.... Phone <br /> Address - City <br /> ;j San Joaquin Pump Co. <br /> Contractor's Name F License U D 7 Phong30_Z f/7/ <br /> Is711 N. <br /> S�gram!gnto St. <br /> Lori, California 95240 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN 1—f RECONDITION/_7 DESTRUCTION fT <br /> PUMP INSTALLATION / / PUMP REPAIR'/a7PUMP. REPLACEMENT f7 ` <br /> j� Other 1E7 <br /> / <br />' .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> qI+ SEWAGE,IDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY'LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL �} <br /> INTENDED USE TYPE OF WELL ' ,,.CONSTRUCTION SPECIFICATIONS <br /> k Industrial Cable Tool Dia. of Weil Excavation <br /> Domestic/private a Drilled Dia. of Well'- Casing <br /> Domesti.b1public I Driven Gauge of rvCasing <br /> Irrigation r,.. `.. a`I Gravel-Pack Depth of Grout Seale_ <br /> Cathodic Pt-66dti6a `" - .Rotary Type of Grout ' <br /> Disposal - Other Other :Information' ' <br /> Geophysical Surface Seal Installed 'B : <br /> PUMP INSTALLATION: .,Contractor } <br /> j Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> F PUMP '.REPAIR:; ... State .Work Done z2e <br /> DESTRUCTION OF WELL: Well Diameter 'Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agr'ee to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the Stateof California pertaining to or regulating well •'construction.. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the Sari Joaquin Local Health District a <br /> WELL DRILLERS P.REPORT of the well andL notify them, before puAting.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 GROU NG AND A FINAL)• INSPECT N. San Joaquin Pump Co. <br /> ~ SIGNED TITLE fbi0gic UF qtr. 4004t1k Sulphur 684 <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> j FOR DEPARTMENT. USE ONLY Lodi,'Colifarnia 95240 <br /> PRASE I <br /> ,.APPLICATION' ACCEPTED BY .� DATE lQ� <br /> ADDITIONAL COMMENTS: <br /> . PHASE II GROUT INSPE ON PKASEjIII/FIVAL INSPECTIO <br /> . INSPECTION BYy DATE INSPECTION DATE <br /> E H 1426 Rev. -74 h/75 2M <br />