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FOB OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1�I601 E. Hazelton Ave. <br /> 9 Stockton, Calif. ' <br /> Telehone <br /> P 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit N0, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE' ISSUED Date 'Issued <br /> Application is hereby made (Complete In Triplicate), <br /> to the Sten Joaquin Local Health District for a <br /> and/or install the work herein described. <br /> County Ordinance .No. This applicatiote ie ieade-in- compliance ermit twithnstruct <br /> San Joaq <br /> 2 186 and t ' Rut d Regul do <br /> t e San Joaquin Local Health Dietric <br /> JOB AIIDRESSJLt�CATIO�S � �7/�'c /V �rD.�pP .. <br /> - CENSUS TRACT 132 -t <br /> Owner's-Name' r� ,J -� !L <br /> Phone ' cS 2 /3 '7 <br /> Address 3 263 .N -12aEcE <br /> Ci-tr— ?'d C1c�v <br /> Contractor's Name San Joaquin Pump Co. <br /> kl31Y151011 <br /> License # 7,0-,37g Phone kmi-sy� <br /> a Caiifo 9'"o <br /> TYPE OF WORK (Check): NEW LL - <br /> { / / DEEPEN /_� RECONDITION I T DESTRUCTION /�- <br /> PUMP INSTALLATIONti�/-7 PUMP REPAIR/ PUMP REPLACEMENT /_7 <br /> Other. L-1 <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL,/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL"—* PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> industrial Cable Tool Dia. of Well. Excavation <br /> Domestic/private Drilled Dia. of Vell Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal. Other Othex Information' <br /> Geophysical Surface Seal Installed 'By: <br /> PUMP INSTALLATIONe Contractor <br /> Type of PUMP ' A.P. <br /> PUMP REPLACEMENT: .' / / State Work Done <br /> PUMP 'REPAIR: /State Work Done pU �S !�P %�iP�,'/elf Ae4e_?0�Pk <br /> bES•TRUCTION 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 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 .of my- knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION TITLE Sae Joaquin Pump Co: <br /> SIGNED <br /> DRAW PLOT PLAN ON REVERSE SIDE (Division of San Joaquin Sulphur Ca.) <br /> FOR DEPARTMENT USE ONLY <br /> • Lodi, Colifarnia 95 �Q <br /> PHASE I DATE ' <br /> APPLICATION ACCEPTED BY 6�uz_ g -7- 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT SPECTION PHASE I FINAL 'INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE __40 <br />