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r /'U <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />FDF ;OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br />Telephone: (209) 466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br />(Complete In Triplicate) <br />Application is hereby made to the Son Joaquin Local 11calth 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 Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />JOB ADDRESS/LOCATION /IUute S'aS l�G� S <br />6 �1a.Gc,et� 2aC /��� Sr CENSUS TRACT <br />Owner's Name /1} Phone 3 0 <br />Address <br />City _AC4 a-( C� <br />Contractor's Name San Joaquin Pump Co. 3�1-��7� <br />License # Phone' <br />717 i.4 inrrn month CF . <br />Lodi, Califo.rnip 95240 <br />TYPE OF WORK (Check) : NEW WELL /%7 DEEPEN -/-7 RECONDITION /% DESTRUCTION /% <br />AL <br />PUMP INSTLATION /—/ PUMP REPAIR ��PUMP REPLACEMENT /? <br />Other <br />DISTANCE TO NEAREST: <br />SEPTIC TANK SEWER LINES PIT PRIVY <br />SEWAGE DISPOSAL FIELD <br />CESSPOOL/SEEPAGE PIT OTHER <br />PROPERTY LINE - PRIVATE DOMESTIC -WELL PUBLIC DOMESTIC WELL <br />INTENDED USE <br />Industrial <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />Cable Tool <br />Dia. of Well Excavation <br />Domestic/private <br />Domestic/public <br />Drilled <br />Driven <br />Dia, of Well Casing <br />Irrigation <br />Gauge of Casing_ <br />Gravel Pack Depth of Grout Seal <br />Cathodic Protection Rotary <br />Type of Grout <br />Disposal <br />Other <br />Other Information' <br />.—Geophysical <br />Surface Seal Installed By: y <br />PUMP INSTALLATION.- <br />Contractor <br />Type of Pump <br />H.P. <br />PUMP REPLACEMENT: <br />/ / State Work Done <br />PUMP.REPAIR:State <br />Work Done <br />a U e <br />DESTRUCTION OF WELL: <br />Well Diameter <br />Approximate Depth <br />Describe Material and <br />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 <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 ofmyknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />PRIOR TO GROUTING AND A FINAL INSPECT N. <br />SIGNED �� TITLE <br />(DRAW PLOT PLAN ON REVERSE SIDE Division o <br />PHASE I <br />FOR DEPARTMENT USE ONLY 7TIN. Sacramento St. APPLICATION ACCEPTED BY Lodi, California 9DATE /525240 <br />ADDITIONAL, COMMENTS: - --- - <br />PHASE II OUT INSPECTION PHASE II_ FINAL RNSPECTION <br />INSPECTION BY L DATE INSPECTION BY DATE <br />E H 1.426 Rev. 1-74 <br />a <br />