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SAN-JOAQUIN LOCAL HEALTH DISTRICT <br /> FOT'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z6_1,9-36l4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED Date Issued Z2-3S 7&/ <br /> - (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 in compliance with San Joaquin' <br /> County Ordina �eft. I 62 and the Rules -and Regulations of the San Joaquin Local Health District <br /> ffOB ADDRESS CATION " E/?. ..CENSUS TRACT -- <br /> Owner's Name Ecu i 4 T Phone , <br /> Address R % /�7� City.,5/�/•yS� <br /> Contractor's Name San Joaquin Pump Co. License # 3163, Phone 3 d b 2/ <br /> MIMMU Of 90-1 1=4-h- <br /> Lodi, Cat9 <br /> TYPE OF WORK (Check) : NEW WELL/ "DEEPEN /_7 RECONDITION /—f" DESTRUCTION f7 <br /> PUMP INSTALLATION '/ / PUMP REPAIR UMP REPLACEMENT /7 <br /> Other J/ <br /> DISTANCE TO NEAREST: EW <br /> . SEPTIC TANK SER LINES PIT PRIVY <br /> t 7- SEWAGE DISPOSAL FIELD CESSPOOL/SEEAGE 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 Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic-Protection- - Rotary.= Type of Grout--. T' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUM1? '.REPAIR: /��State Work Done C� w <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 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPE N. <br /> SIGNED TITLE Son j <br /> (DRAW PLOT PLAN ON REVERSE SIDE (Division of Son happin <br /> FOR DEPARTMENT USE ONLY I I I N. Sacramento St. <br /> PHASE I l oli, r.UUrfnr^:o 95?, <br /> APPLICATION ACCEPTED BY C . DATE '/D <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION IF PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ti E S 1426 Rev. 1-74 r W75 2M <br />