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. � SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> FOR OFFICE USE': 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 71S`1) a` Vj <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73-L97 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 4 14/7,3 <br /> (Complete In Triplicate) <br /> Application is hereby made 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 Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �D Underwood Rd CENSUS TRACT <br /> Owner's Name IlQbgrt Cleaves__ Phone <br /> Address 107__Lincoln Ave City Lodi <br /> Contractor's Name DgMgatic ervice - License # 114455 Phone368o4004 <br /> TYPE-OF .-WORK (Check) NEW WELL /jV- DEEPEN%_7`�RECONDITION /_7 ;DESTRUCTION /_7 <br /> 'PUMP INSTALLATION _ PUMP REPAIR / / PUMP REPLACEMENT /? t <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 ..y <br /> Industrial x Cable Tool Dia, of Well Excavation _ <br /> Domestic/private Drilled Dia. of Well Casing 8"-- <br /> Domestic/public <br /> "-Domestic/public Driven Gauge of Casing =1 V ga <br /> X Irrigation Gravel Pack Depth of Grout Seal �0f' <br /> Other Rotary Type of Grout Sand & cement <br /> Other Other Information ' <br /> i <br /> 1 <br /> PUMP INSTALLATION: Contractor <br /> _--- tom®$tl-a Pump Service <br /> Type of Pump Submersible H.P. 3 H.P <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WE : Well Diameter <br /> .p WELL: 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 a <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. <br /> SIGNED TITLE i <br /> i <br /> (DRAW PLOT PLAN ON REVERSE SIDEj <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ��i �c' -- -- - - DATE <br /> ADDITIONAL COMMENTS: - ` � <br /> PHASE II GROUT INSPECTION PHASE III FINAL 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 />