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•- SAN JOAQUIN LOCAL HEALTH bISTRICT <br /> FOR OFFICE USE: .1601 E. Hazelton Ave. , Stockton, Calif. � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> _ 1p*� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' -� fCr✓+J�4r. f, (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 Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ECAs T s1,0 r oeQ e s rp6 s R o --#41 •cro/.w-w a,4 t <br /> JOB ADDRESS/LOCATION <br /> S_e•, $e-etc C'a�t <br /> vie R fl sr ENSUS TRACT <br /> w +?32� [� �cru5e_, • /Zcdi•� �C <br /> Owner's Name g_�u► a c1 i PA r-jr-1.V 6, Phone `- z 7 7k <br /> Address ,Z 1 ti ----- <br /> city /c !d <br /> Contractor's Name Son ,Joaquin Pump Co. Phone <br /> 3t / SL/7 <br /> License # <br /> (9ivisissno anJoaquin- Sulphur Co,j• ,_.�•,.--.,,,,��.-. -��,.,:--v- r,� �,�..�-�.„_. „-.—„,_..� , <br /> TYPE OF WORK (Check) : M pE&9�-I'-”IEEPEN J RECONDITION ./ DESTRUCTION /- A <br /> 11 <br /> PUMP INSTALLATION / / PUMPREPAIR /t4---PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED',USE TYPE OF WELL---,.. F' , CONSTRUCTION SPECIFICATIONS <br /> Industrial Cabld 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 /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. N)l <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /! yState--Work-Done <br /> R� - <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 F <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS x <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. <br /> SIGNED San Joaquin Pump Co. <br /> TITLE 01yision of San Joaquin Sulphur Co.) <br /> (DRAW PLOT PLAN ON REVERSE SIDE) 711 N. Sacramento St, <br /> R to o Y FD k -rVS p&�7/041 FOR DEPARTMENT USE ONLY Lodi, California ;) 4t <br /> PHASE I ----�- �_--� — <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL, COMMENTS: k <br /> PHASE II GROUT INSPECTION PHASE III/ AL INSPECTION ; <br /> INSPECTION BY DATE INSPECTION BY [' DATE j-, 4&-Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO i <br /> E H 1426 7/72 1M <br />