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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> (/$ <br /> FOE,OFI'E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77�5� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) k <br /> Application is hereby made to the San Joaquin Loc licatinnHealth Distmade inrict rcompliance a permit twith San Joaquin <br /> PP <br /> and/or install the work hexein described. This PP # <br /> Dunt Ordinance No. 1862 and'the Rules and Regulations of the SansJoo r�n Local Health District. <br /> County r-ie s r ozc.v d P <br /> J6 CENSUS TRACT <br /> JOB ADDRESS/LOCATIONS <br /> Phone <br /> Owner's Name <br /> �/a21.] /7 <br /> -- City <br /> Address <br /> E San .Joaquin Pump Co. License Phane ul <br /> r Ca.) Z <br /> Contractor's Name c amento St. <br /> Lodi, California 95240 RECONpITION /�./ DES FRUCTION. /-7. <br /> DEEPEN / / _TYPE-OF WORK -(Check)-:-7--NEW- /�T - PUW REPAIR / tTMP REPLACEMENT 17 <br /> PUMP INSTALLATION / P <br /> Other-/ / <br /> _ SEWER LINES PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE PI�- OTHER <br /> SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> k PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS X) <br /> 4 INTENDED USE TYPE OF WELL <br /> Cable Tool Dia. of Well Excavation <br /> Industrial� Drilled Dia. of Well Casing <br /> DrV <br /> Domestic/private O Driven .. Gauge_of Casing, <br /> Domestic/public j T r <br /> Gravel Pack Depth of Grout <br /> Irrigation Seal <br /> Rotary-_ - Type of Grout' <br /> Cathodic-protection ' ' Other �� Other Information <br /> k Disposal -- 5ur4ace Seal Installed B <br /> ` Geophysical <br /> Contractor H.P. <br /> PUMP INSTALLATION: <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Done <br /> 4:.. -.i /e • Sue una <br /> ' pump ,REPAIR: /,fjState Work Done pp <br /> Approximate Depth = -�-- <br /> DES1RUCTION�OF=WEDD� Descrll ibemMaterial and Procedure <br /> lL <br /> rict <br /> I hereby agree to comply with all laws and regulations <br /> Of well.ecSan o ction.LoWithin cal aFIFTEENtDAYS <br /> and the State of California pertaining to orregulating <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health above <br /> District <br /> WELL DRILLERS REPORT of the well and notify mandfore belief putting <br /> I WILL CALL FOR A GROUTeINSPECTION <br /> . information is true to the best of my knowledgeSan Joaquin Pump Co. <br /> F PRIOR TO GROUTI D <br /> �FTN�INSPEC <br /> TION TITLE <br /> p rur n., ; <br /> SIGNED W P3i, TPLAN ON RE EASE SIDE) <br /> FOR DEPARTMENT USE ONLY Lodi, Califoreiia 95 g0 <br /> PHASE I DATE <br /> APPLICATION ACCEPTED .BY ' <br /> ADDITIONAL COMMENTS: ON PHASE III FINAL INSPECT ON <br /> GROUT INSPECTION DATE` <br /> � <br /> PHASE II INSPECTION BY - <br /> INSPECTION BY DATE <br /> ! . 3/76 2M <br /> �• F x 1426 Rev. 1-74 <br />