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v49r / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FpF�' OF'FxCE tJSL: I/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THiS PEitMIT EXF'IRSS ]. YEAR MOM IlATE'I$Si�'ED Yate' Issued. <br /> (Complete In Triplicate) - GbQ_0-no 03 <br /> Application is hereby shade to the Sae JOaquitt Local 11dOlth'District-for a permit to construct <br /> and/or install the work herein described. This applicatiati"ie'siiac3e ie"casnpliaace with Sae Joaquin <br /> County.. ' rdimmee No. 1862 'and the Rules and ReguUtions� s=f t�ts3 San �o <br /> IIIWLd Locel'Health District. <br /> l ... �1io�.�a s..o� oX' L.�eeTj- �oa,:i �.j <br /> .TOB ADDRBSSJLOCATI �.�s� ►c 77w6 av t CEtlSUS TRACT <br /> Owner t a:!Name uz jEwu f <br /> i <br /> !}lone <br /> Address <br /> qty 5'//�.tr6/� <br />' + Son Joaquin Pump CO.' <br /> Contractors NBtee <br /> --• 4Oiiaaionnf,$Ga.,lRld$IAft--gulehu.Ce1 License <br /> 711 <br /> Lodi, California 95240 <br /> TYPE OF—WORK (Check)t NSW WELL .0 DEMPEN'/-7 RECONDITION t7 DESTRUCTION 17 <br /> PUMP INSTALLATION 0 PUMP-REPAIR'�FME REPLACEMENT <br /> Other ./7 '� <br /> DISTANCE TO NEAREST: SEPTIC <br /> TANK R LINES PIT PRIVY 1 <br /> SEWAGE DISPOSAL FIELD - CBSSPOOLAMMAGM PIT OTHER � <br /> PROPERTX LIN - PRIVATE DOMESTIC Wrd.--'— <br /> PUBLIG STIC WELL <br /> C INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS r1 <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 Protection Rotary Type of Grout " <br /> Disposal Other Other Information' ' <br /> Geophysical Surface Seal Instal ed B <br /> X I <br /> PUMP INSTALLATIONS Contractor <br /> Type of Pua� <br />� _.�.....,....,, , ,,,._,........,..�,,.,.._,.,.... � S.P. <br /> PIMP REPLACEMENT: J..! State Work Done <br /> PUMP '.REPAIR; tate Work Done �KM;L0 <br /> DES-`RUCTION OF WELL: . Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby„agree to comply with all. laws and uegu]ations of the San Joaquin Local Health Distract <br /> and the $tate of California pertaining to or regulating well''construction. Within FIFTH DAYS <br /> after c016pletion of my work on a new well., I will furnish the San JosqulmC Local Health'District a <br /> WELL DRILLERS REPORT of the well and notify them before putting..the..well •in.use-.. .The above <br /> inf ormation is true to•the•best,of..my.knowledge and belief. I WrLL CALL 'FOR'A'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSpUTION. San Joaquin Pump Co. <br /> SIGHED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE sommoug At <br /> ro <br /> DEPAaTMENT <br /> PHASE I USB.ONLY Lodi, Calitarnia 95190 <br /> .. <br /> APPLICATION ACCEPTED BY DATE'�E�o` <br /> ( "'!)ITIONAL COMMENTS: <br /> PHASE XI GROUT INSPECTION PSk,Sg Y FINAL MI-PECTI i <br /> INSPECTION $Y HATS a1SPECTION BY DATE a <br /> i� <br /> E a 14+26 Lt/75' 2M { <br />