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/�1601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTFOTY,OFFIGE USE: E. Hazelton: Ave. , Stockton, Calif., Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> YEAR FROM DATE ISSUED Y <br /> THIS PERMIT WIRES 1 Y <br /> �r�a���3����'iF CRc•5�a„'� , �_ Date Issued �.Sr <br /> Application ie hereby' made to the San(Complete <br /> Lo alr Iealth Distri ®� C3orr <br /> ict <br /> and/or install the worts herein: described. This application is made inrcompliancea permittwith nSan uJoaquin <br /> County -Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ! Ge4%veeV Sckf& 4- a teoc: Ro <br /> JOB ADDRESS/LOCAT'ION L S ��'-�'�� S &rye <br /> l - �'�e¢ �` 1 CENSUS TRACT <br /> Owner'e'' Name G—e a rz �e 3 <br /> - Phone <br /> Address, j <br /> "' I "� L , r3 c rz f- �u►� c� <br /> City G-46-r <br /> San Joaquin Pump Co. <br /> Contractor's Name .(Division of Son Joaquin Sulphur Ce.) <br /> 5U0 E ett eman License # Phone .361-S y?/ . <br /> A ornra95240 <br /> TYPE OF,,WORK (Check): NEW WEL� /? DEEPEN '/? RECONDITION /—_7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR ,� PUMP REPLACEMENT <br /> Other E7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> PROPERTY LINE -- PRIVATE DOMESTICSWELL/SEEPAPUBLIC DOMESTIC E PIT WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 6mesti' Cable tool Dia. of Well Excavation <br /> Dgmestic/private' _ Drilled Dia. of Well Casio <br /> Da'mestie/public .�w Driven g - <br /> Irrigation Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information , <br /> Geophysical Surface Seal Installed B ~ <br /> � i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: State Work Done � <br /> PUMP '- <br /> REPAIR: / tate Work Done ' <br /> Ad '70 CEJILEArAJ _3 7 kee&a,e, (4 L �. <br /> DES TRUCTiON OF WELL: Well Diameter <br /> Describe Material, and Procedure Approximate Depth 4_ <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 <br /> WELL DRILLERS REPORT of the well and notify them before putting. the..well in.use.... The above r <br /> information is true to the-best of- my knowledge and belief. I WILLCALL FOR A GROUT INSPECTION <br />?RIOR TO GROUTING AND A FINAL I PECTION. <br /> SIGNED an Joaquin Pump Co. <br /> TITLE (Division of San Joaquin sulphur <br /> (DRAW PLOT PLAN ON REVERSE SIDE ettleman <br /> PHASE I_ FOR DEPARTMENT USE ONLY i, o I ornia 524LJ <br /> APPLICATION ACCEPTED BY <br /> kDDITIONAL COMMENTS: DATE � J` 7 <br /> PHASE II OUT INSPECTION PHASE III FINAL INSPECTIO <br />[NSPECTION BY DATE INSPECTION BY DATE / y <br /> E H 14!.26 Rev. 1-14 - - _ 1t/7 C� ' <br />