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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. et <br /> Telephone: (209) 466-6781 <br /> \AiPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> j _ L_39 0i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1--1a2-7� <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: Na. 1862 and the Rules and,Regulations of the San Joaquin Local Health District. <br /> 4EA' ST� FRov'TRG€ ',ec aa, SC0.-N of mo2AOA° JOB ADDRESS/LOCATION s,�Til. sro a „r CENSUS TRACT j <br /> Owner's Name L- ' _g - T IAe a Ke4j 5I IAC <br /> Phone .3 70 <br /> Address 576 SSS' E� 111-140P&_71_'1 City STaGle-Tca.cl f <br /> ` Son Joaquin Pump Co. <br /> Contractor's Name License. # Phone �� <br /> l <br /> _," "� - ,&,CalifQr-nia_95240 _ i <br /> TYPE OF WORK (Check) ; NEW WELL /� .DEEPEN /_� RECONDITION /_� DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> I� Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY { <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE -s- TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled 4 Dia, of Well Casing ' <br /> Domestic/public Driven Gauge of Casing G\ � <br /> Irrigation -i Gravel Pack Depth of Grout Seal- <br /> Other _t Rotary Type of Grout. <br /> Other Other Information <br /> c <br /> PUMP_INSTALLATION. Contractor A,1 ZoAQ cdr-J At^p CCa, Uj4Ak b f' LVAHL 4 kdbo Q5 <br /> Type Of Pump -rA [ 2$�.cs� H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: <br /> / / State Work Done <br />,DESTRUCTION OF WELL,: X11 Diameter _ __ 4 <br /> 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. ndtify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNEDti � <br /> t <br /> f TITLE Son Joaquin p[Imp Co. � <br /> (DRAW LOT PLAN ON REVERSE SIDqWn bulphur Co.) <br /> OR DEPARTMENT USE ONLY �" "'°" "` ' <br /> PHASE I Lodi, California 9524 <br /> P 0 <br /> APPLICATION ACCEPTED.BY f DATE <br /> ADDITIONAL COMMENTS: [ , <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE :�G <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING.AND FINAL INSPECTION. ,y <br /> E H 1426 'lf'" 7/72 1M <br />