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1 <br /> 4F0,';,1FF1CR USE: - �/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Razelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATIONFORW3:LLCONSTRUCTION OR PUMPPERMIT Permit No.. ' .�_.��.�_ <br /> THIS P <br /> T MM''RES 1 YEAR FROM DATE'18-SM D <br /> Appllceriott is he (complete in Triplicate Dere I$sued <br /> rib ) <br /> and/or y made to the Sart Joaquin Local Healy apr-permit <br /> I iaetall the work herein described_ . This applicationDIs rade'fncc ti C k with t aaJaagnl:t <br /> Couaty '�4rdinance No: 1862 and' the Rules Bad Regulations of the' -San joagtdn Local.Health District. <br /> �(a f?r!1� . �f 4�.G rfa�'f/ y-igr OF Li�S6.¢Tf' �At? -� rA.lBs <br /> JOS ADDRESS/LOCATION F �' ESS T <br /> ' 'CEN8178 'TRACT — _ <br /> Owner'sll Name _. <br /> Phone <br /> Address9.� <br /> City6 Sfjf�j[� <br /> Contractor's Name San'Joaquin PUMID Co <br /> �sEon o ,an oaga n o p ar Co.) Lice"@ # � I� Phone <br /> TYPE 01%WORK (Check): W6BIz" 24SMSPM , <br /> '/�" RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION'L7 FUMp REPAIR L"7 p RgPLACT <br /> Outer ,�j � <br /> DISTANe TO NEAREST: S$PTIC,TANK s> wER LINES <br /> SEWAGE DISPOSAL VIS PIT AGEPRIP <br /> PBOPLRI'Y LINE -- PRIVATE�� CESS 4L/SEEPAGE PIT �R <br /> INTENDED US$ STIC WELT.' PUBLIC.DOMS TC WELL' <br /> TYP13 OF.WELL CONSTRUCTION SPECIFICATIONS °fti <br /> ndustrial �_ Cable Tool Dia. of Well Excavation ~ - <br /> �.,,.__ Dc!mastic/private Drilled Dia. of Well Casing N <br /> 114mestIc/public + Drives <br /> Irrigation Gangs of Casing , m <br /> ,,� r Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectionRotary Type of Grout <br /> Disposal ' Other Other infortaatioa' <br /> —Geophysical <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT'; , & State Work Done <br /> PUMg �REPAIR: L__7 State Work Done <br /> DESTRUCTION OF DELL: Wall Diameter <br /> Describe Mater. and P::ocedure Approximate Depth _. <br /> I herehg,Statagree to alifor with all laws and regulations of the San JoagUIn Local Health District <br /> and the State of California pertaining to or regulating <br /> after c4inpletion of my work owell''Construction. ldithin- FIFTEEN DAYS <br /> WELL DRILLERS REPORT of n a new well, I will furnish the San Joaquin Local Health District a <br /> information 18 ' the well and notify them before putting.-the..well- in-nae.... The above <br /> true to the-best-of- my..knowledge and belief. I WIL <br /> SIGNED A FINAL INSPECT N. L <br /> A <br /> >'RIOR T0'GROTITING AND CALL FORZROU'T INSPECTION <br /> _ <br /> TITLE San Joaquin Pump Co. <br /> RAW PLOT PLAN ON REW ME SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> Al' LF I� IUTION' ACCEPTED BY Lodi, California 95240 <br /> AMITIONAL COt4NTg; DATE '� _ . <br /> PHASE Yx GROUT INSPECTION <br /> IftSFECTION P E III FINAL =9PECTI N <br /> gy DATE INSPECTION BY 1 <br /> Y <br /> DATE /a I <br /> E H 1426 Rear. .1-74 i <br /> f L!'ir5 2N <br /> f <br /> i <br />