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. r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued.. ✓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 No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION.Sa k-11 I1WA.) C...) BP�ic��.�J dG�a ,q /�wy 8� CENSUS TRACT <br /> Owner's Name y ,4 t Phone 3341— 0/67 <br /> Address ^ "%L _ AAf City `` L 4 D7 <br /> Contractor's Name San Joaquin Purnp Co. License 9� o Phone [9 t 71 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL <br /> 7 DEEPEN / I RECONDITION /� DESTRUCTION /� " — <br /> PUMP INSTALLATION/ / PUMP REPAIR/77-"PUMP REPLACEMENT /7 <br /> Other j-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled .Dia. o£ Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack _ Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done A&V ,�,J rp fU•fB�ti6 <br /> DESTRUCTION OF WELL: Well Diameter 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION San Joaquin Pump Co. <br /> SIGNED - TITLE (Division <br /> RAW PLIDT PLAN"ON REV8RSE SIDE) 711 Ccr me f' <br /> FOR DEPARTMENT USE ONLY Lodi, California 95240 <br /> PHASE I r7 <br /> APPLICATION ACCEPTED BY DATE � t <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY . � DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />