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SAN JOAQUIN LOCAL, HEALTH DISTRICT <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, 7...� � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued = lf �.: <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 application is made in compliance with San Joaquin <br /> County Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> r <br /> JOB ADDRESS/LOCATION Intersection of Tokay & Fairmont Streets CENSUS TRACT <br /> Owner's Name ALADDIN REAL ESTATE- Phone 334-2141 ' <br /> i <br /> Address - 330 South Fairmont Avenue (P. 0. Box 797) City Lodi <br /> M <br /> Contractor's Name r License # Phone <br /> s Vel <br /> r - <br /> TYPE OF WORK (Check) : NEW WELL /_/ DEEPEN '/_/ RECONDITION /_7 DESTRUCTION /)( <br /> e PUMP INSTALLATION / ./ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD' CESSPOOL/SEEPAGE PIT OTHER <br /> e ' PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL r - <br /> j INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I Industrial Cable Tool Dia. .of Well Excavation Q <br /> Domestic/private Drilled Dia. -of Well -Casing- .- <br /> Domestic/public <br /> asing_ .Domestic/public Driven Gauge of <br /> Irrigation Gravel Pack Depth- of Grout Seal , <br /> Cathodic Protection Rotary Type !of Grout <br /> Disposal Other Other. Information <br /> Geophysical F Surface Seal Installed By: <br /> PUMP INSTALLATION:` Contractor. - <br /> .Type of Pump 3 H.P. <br /> PUMP REPLACEMENT: / / StateWork' Done{ <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter -Anknown Approximate Depth <br /> Describe Material and Procedure Fill casing with &&Per -te to well -head <br /> and 'remove we.l l i t: e2,s-� p�� e- c.J�A <br />� I hereby agree to comply with all laws and regul tions of the tan 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 f . <br /> information is true to the best."of my.-. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> t,PRIOR TO GROUTING AND 'A -FINAL IhtSPECTION.­�- <br /> t SIGNED T TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY— <br /> DATE *��• G-77 <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br />! INSPECTION BY , - w.-- DATE .».. TNSPECTION,BY_ DATE Ay--26 ' -7/ <br /> i�I�; „ <br /> . E H 1426 Rev. ].-74 2M <br />