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C � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF>:.OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)+ 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-753� <br /> THIS PERMIT EXPIRES 'l YEAR FROM RDATE VISSUED Date Issued f <br /> (Complete In Triplicate). <br /> Application' 'is hereby made Cn1the San Joaquin Local Health District .for ,a permit to construct.. <br /> and/or install the work herei� described. This application is made ,in compliance with• San:,Joaquin, <br /> County Ordinance No. 1862 an&i the Rules and Regulations cif the ,San :Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .45'17 622 - /L CENSUS TRACT _. <br /> Phone 6ff f S-Z. <br /> Owner's Name' ) SSe Lr.r�Q <br /> Address el. AIWL "City <br /> Contractor's Name San Joaquin Pump Ca: �, License .#3&3 37 Phone 71 <br /> (Division o on Joaquin �. .; <br /> f - — �d,, Ga nen 95240 �- i; <br /> F TYPE OF WORK (Check)! NEW.WELL DEEPEN '/-7" RECONDITIONS _ DESTRUCTION /� . <br />' PUMP INSTALLATION I / PUMP REPAIR-/� PUMP REPLACEMENT I <br /> Other l/ <br />' .DISTANCE-TO NEAREST: SEPTIC 'ITANK SEWER LINES i.r -PIT PRIVY <br /> SEWAGEfDISPOSAL -FIELD CESSPOOLISE'8PAGE PIT OTHER R1 <br /> PROPERTY LINE - PRIVATE DOMESTIC/WELT- i PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL p CONSTRUCTION SPECIFICATIONS <br /> Industrial CableTool v- Dia. of Well. Excavation <br /> Domestic/private i ."Dri.11.ed Dia. -of Well 11Casing <br /> . <br /> Domes tic/puVl;ic Driven Gauge of Casing , <br /> Irrigation r Gravel Pack Depth' of Gr&ut Seal <br /> Cathodic Protection 1 RotaryT}►pe of Grout" <br /> Disposal ri Other Other Information <br /> Geophysical _ Surface Seal Installed BY: Y <br /> : PUMP INSTALLATION: . <br /> Contractor .0 ». . <br /> Type of Pump H:P. <br /> PUMP REPLACEMENT: /ET"-State tate Work Done , <br /> , PUMP .REPAIR: / ! State Work Done <br /> � I}ES•TRUCTION OF WELL: Well.•Aiameter 1. Approximate Depth <br /> Describe Material and Procedure <br /> f _ <br /> 11 hereby agree co a to l .wi.th. all laws and regulations of the San Joaquin Local Health District ' <br /> � � <br /> and the State of California' pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work"bn 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 INSPECT N.. ' <br /> SIGNED TITLE 5aff loaqum Pump"Co. <br /> (DRAW PLOT PLAN ON REVERSE SIDE San oaGum u!p(�Ur.>bg,� <br /> FOR DEPARTMENT USE ONLY Lodi,,California 95240 > t <br /> PRASE I a <br /> APPLICATION ACCEPTED BY DATE2 <br /> ADDITIONAL COMMENTS: . <br /> PHASE -II GROUT INSPECTION PHASE III FINAL INSPECT 0 <br /> eINSPECTION BY DATE ¢ INSPECTION BY & __DATE 101,31 � . <br /> R H' 1426 _'_R 1-74 <br />