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ff� <br /> ft. ' el SAN JOAQUIN LOCAL HEALTH DISTRICT 4 <br /> FOFirOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,s <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 appl'icat'ion is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> CUC�3!514E Zoe-a$ 7zce AVID 419-T Jr2 M-1 VcrrTifi <br /> JOB ADDRESS/LOCATION o,c f/ aA eE - GAF CENSUS TRACT <br /> Owner's Name Phone I"` &�V 54Lr <br /> Address I V V13 ADAD City Z o D•I <br /> Sari Joaquin Pump Co. <br /> Contractor's Name - --_ivision of Son Joaquin Sulphur Co.) _ .,_ .� License #210373 Phone 3yl�-15/7/ <br /> 711 N. Sacramento St. <br /> Lodi, California <br /> TYPE OF WORK (Check): NEW WELL '/7 DEEPENJ7/? RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR '/_ PUMP REPLACEMENT 47--- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES~ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD "x 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 4 <br /> Domestic/public Driven Gauge of Casing �� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Proteet__ion '" Rotary 'Type of Grout'' \� <br /> Disposal Other Other Information \� <br /> Geophysical. Surface Seal Installed 'B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . State Work Done /,S-.S<P &e&yje_7z71—-/20& d&d$igfE <br /> PUMP ,.REPAIR: / "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 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 GROUTIN ANDA FINAL INSPECUON. <br /> SIGNED'— TITLE Sar: Joaquin Pump Co. <br /> DRAW PLOT PLAN ON REVERSE SIDE)_ insion o an Joaquin sulphur CO.) <br /> FOR DEPARTMENT USE ONLY c <br /> PHASE I Lodi, California 9 24 <br /> APPLICATION ACCEPTED BY � ' DATE '- <br /> ADDITIONAL COMMENTS: 0a F <br /> PHASE II GROUT INSP ION PHASE III FINAL INSPECTI9 <br /> INSPECTION BY DATE INSPECTION BY DATE O <br /> E H 1426 Rev. 1-74 r 4/752M <br />