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<br /> SAN JOAQliIiT LOCAL HEALTH DISTRICT
<br /> 'ICE uE-
<br /> 1601 E. Hazelton '
<br /> Ave..,
<br /> Stockton, Calif. G G4
<br /> Telephone: (209) 466-6781
<br /> "`• APPLICATION FOR WELL CONSTRUCTION OR PU p
<br /> 3` r
<br /> THIS PERI-11T EXPIRES I YEAR FROM DATE UEB"r Date Is �LZ
<br /> — sued V
<br /> . (Complete In Triplicate)
<br /> k' s �yPPlication is hereby made to t`ne San Joaquin Local 1fealth District for a permit to construtet+ ,;
<br /> and/or install the ,cork herein described. This application is made in compliance with Sari Jne i`_
<br /> County Ordinance No. iin
<br /> 1862 and the Rules and Regulations of the San Joaquin Local Health Dis q
<br /> g JOB G7y7 tcict.
<br /> ?: ADDRESS/LOCAT�.ON
<br /> k �B =pEJtfA �� ENSUS TRACT. A+ €
<br /> y" Owner's Name
<br /> Phone
<br /> Address
<br /> ------------
<br /> City F
<br /> �15y g;J Contractor's Name San lnaauin Pump Co.
<br /> $fir. --• --- License Phone� LCLZ�L� k
<br /> I;;�,T TYPE 05' WORK (Check):
<br /> NEW WELL /? L�EEPE�N��� — p
<br /> srg� rta., /� RECON[lITION DESTRUCTION
<br /> PUMP INSTALLATION /; PUMP RRPILIR / / PUMP REPLACEMENT 'SM1
<br /> Other /7 f,
<br /> DISTANCE TO NEAREST: SEPTIC TANK_ - = ,
<br /> SEWER LINES PIT PRIVY
<br /> SEWAGE. DISPOSAL FIELD
<br /> ear CES:�P001"/SEIsPAGE PIT _ - OTHER
<br /> s, .•., PROPERTY LINO - PRIVATE T?OMESTIC WELL FUBLIC DOMESTIC WELL ,; ;r�
<br /> INTENDED USE TYPE OF WLLL
<br /> 6 5 Gr
<br /> i a - ---_ CONS':°UCTION SPECIFICATIONS
<br /> Inu,tr_aJ. Cable Taal , Na�
<br /> 5a /private _ Drilled Dia. c._ Well Excavation,
<br /> Domestic Dia, of Well Casing +
<br /> Domestic/public
<br /> Driven Gauge of Casing ;,-Irrigation Gravel Pack Depth of Grout Seal , 'cif
<br /> �� ' Cathodic Protection _ y Type of Grout
<br /> tea T Rotor V
<br /> Disposal Other -
<br /> Other Information
<br /> Geophysical
<br /> Surface Seal Installed ByT�W
<br /> PUMP INSTALLATION: Contractor
<br /> Type of Pump l =
<br /> H.P.
<br /> PUMP REPLACEMENT: ^
<br /> } state Work DoneTP
<br /> a _
<br /> PUMP .REPAIR: / / State Work Done i','
<br /> Z k `,%Xv DESTRUCTION OF WELL: Well D:iemerer
<br /> ' 'a, � ��� Approximate Depth a
<br /> �,`{ bescr::be Material and Procedure —
<br /> f s, —
<br /> t, � ' u I hereby agree to, comply tait';� all laws and regulations of the San Joaquin Lccal Health District '
<br /> -, f;F and the•State of, California pertaining to or regulating
<br /> % � _-' grae 11'�construction. Within FIFTEEN PAYS
<br /> + t H .after completion of my work on a new well, I will furnish the San Joaquin Local Health
<br /> WELL WELL DRILLERS REPORT of the well and notify thea before putting the well in use. The ab' V,6." f
<br /> ¢ � information is true to the best of my knowledge and belief. T WT
<br /> LL PRIOR TO GROUTING F'IN L NSPECTION W..LL CALL FOR A GROUT INS%CCTIONk I.k;
<br /> SIGNED TITLE San Joaquin Furip
<br /> ily ;5 (D d PLOT PLAN ON REVERSE SIDE ""' OF
<br /> Fiil }
<br /> FOR DEPARTMENT USE ONLY
<br /> PHASE I Lodi Cali'
<br /> 95240
<br /> I
<br /> 33 APPLICATION ACCEPTED BY
<br /> ADDITIONAL COMMENTS: _ DATE
<br /> PHASE II GROUT 1NSPECTIO :F-
<br /> : P1USE II I IFI'[vAL INSPECTION
<br /> INSPECTION Bi DATE - INSPECTION BY '
<br /> DATE ,S—:_L G J
<br /> E 11 1426 Rev. •1-74 ti�77
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