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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> F-06�0PFICE USZE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7?. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE-.ISSUED Date Issued 62.� 2z <br /> ."(Complete(Compl:ete 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..riade .in compl,�iance with San. Joaquin.1 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San. Joaquin .Local Health District. �rjl <br /> JOB ADDRESS/LOCATION s414412y� CENSUS T•RACT ' , T r <br /> Owner's Name V1 AJ L Phone 36 9 91 SZ <br /> oZ cC sd ,�.3 �,4C t_-r _ <br /> - --- - [Y�PISn t� Ci <br /> Address*—, e� <br /> Ac�1��4 <br /> San Joaquin Pump Co. ' <br /> Contractor's Name �n;,,,t;,�„ „F Sn <br /> nn Inouin Sulphur Co.) License . Phone <br /> / 7 <br /> _ ._ acramenta- t.—• -� <br /> _ Lodi, CaMa.rnia 95240 <br /> TYPE OF WORK `(Check).__ NEW WELL /? DEEPEN_'/__ RECONDITION' /-T DESTRUCTION <br /> PUMP INSTALLATION-/ / PUMP REPAIR /i. ~PIW REPLACEMENT 17 - <br /> Other - <br /> Other <br /> E. 'I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY I <br /> k. SEWAGE DISPOSAL..,FIELD CESSPOOL/SEEPAGE PIT ' OTHER <br /> PROPERTY LINA PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ` : <br /> INTENDED USE _w . � „ ,TYPE OF WELL"1 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 <br /> ealCathodic Protection Rotary Type of Grout Disposal. Otherr_.-_�Y R_.__�__O.therr Information-� <br /> Geophysical Surface Seal Installed By: .. ... . . <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump n y H.P. <br /> f ; <br /> PUMi? REPLACEMENT: .. E7 State Work Done ,Z, <br /> PUMP '.REPAIR: / Mate Work Done . LOu . 6 <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 anew 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 i' <br /> information is true to the•best .of my knowledge and belief. I WILL CALL FORA GROUT- INSPECTION r <br /> PRIOR'TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDTITLE San Joaquin Puimp Co. <br /> (DRAW PLOT PLAN ON REVERSE SIDE iwsiop o . an Joaquin Sulphur Co.) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Lodi,-ColifoTnij 9524 <br /> APPLICATION ACCEPTED BY &VV DATE Z f <br /> 1 ADDITIONAL CONRENTS a ILw <br /> PHASE II GROUT• INSPECTION PHASE II FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE 6 �6 <br /> r E H 1426 Rev. 1-74 f' -- - 2N <br />