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SAN JOAQUIN LOCAL HEALTH DISTRICT- <br /> i�UR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. c(a <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �z;3 <br /> 76��6 , <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date' Issued 6-If- 6 <br /> (Complete In Triplicate) <br /> Application is hereby inade 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.-Ordi ance -No. .1862 -and the Rules and Regulations of the, San Joaquin Local Health District. <br /> . GUPS T S• 13 P L va -• 6 P� �- <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name -2, ,� ' At j siJ Phone <br /> LccAddress City C�00 / <br /> Son Joaquin Pump CO. <br /> Contractor's Name _ "' License 4t Phone (,�-S7I 1 <br /> /1]G�isintt of Snn Joaquin Sulphur Co.) y <br /> 711 N. Sacramento 5t- <br /> Lc�i, Calitornia nLw <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 jRECONDITION /_Z� DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR /LREPLACEMENT /? <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 / 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', _t° ,^r 5'Gravel-Pack {Depth of Grout Seal <br /> Other -- Rotary --- -Type of Grout" <br /> .OtherOther-information <br /> PUMP INSTALLATION Contractor <br /> s Type of Pump H.P. <br /> k PUMP REPLACEMENT: /State Work Done <br /> r PUMP REPAIR: /ZJ" State Work Done ZZ2"_72-14&C18 <br /> ESTRUCTION OF WELL; Well Diameter Approximate Depth <br /> Describe Material and Procedure i <br /> f <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 a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above r <br /> information is true to the best of my knowledge and belief. <br /> E <br /> SIGNED TITLE Saco ,Joaquin Pump Co. <br /> 4 DRAW PLOT PLAN ON REVERSE SIDE ' • ' <br /> PHASE 2 <br /> FOR DEPARTMENT USE ONLY Lodi, Califarniu 9.5410 <br /> ! �/ <br /> APPLICATION ACCEPTED BY DATE f�( <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FIN _ INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION, <br /> E H 1426 7/72 1M <br />