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fl _--JSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO—E""6-HFICE USE: V-� 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone ; (209) 466--6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> k I! <br /> i THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 3Q_f� <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 wi.th .San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> fo 49 <br /> ow <br /> JOB ADDRESS/LOCATION (i?A7"E2Loo kd -- ' ,D e S ,.-i a CENSUS TRACT 101-�.` �? <br /> 'ro itJ p W Hous-e- Lea oP 2 c"c>u 7-,e c4l 'ad o/ Ea S+ O F a..,m i to L at lt/P - <br /> t Owner's Name L Phone 9S�^-_91 29 <br /> Address 1 - <br /> I2 lv�(a2eo C.�.c, city S 0c,_7-�1 <br /> Contractor's Name San JLquin Pump Co. License #-?Ajj6 Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION /�MP REPAIR / / PUMP- REPLACEMENT <br /> Other / / — <br /> �r. <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 USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool\ ` `Dia:.of Well Excavation <br /> Domestic/private Drilled F Dia, of Well Casing <br /> Domestic/public I 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 o f Pump �ri'7�.�. '/•G� �.i �— H.P. <br /> PUMP REPLACEMENT: / / State Work -D- <br /> one <br /> r � <br /> F PUMP .REPAIR: / / State Work :Done.: <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r � Describe Material,'and Procedure <br />� 1 � <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 /> F WELL DRILLERS REPORT of the ell and notify them before puttingthe- well in use.... The above <br /> information is true to the best of. my knowled e and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ANINAI! I SPE San Joaquin PPMP Co. <br /> SIGNED TITLE <br /> (Division QF San Joaquin S�Ipkur Co.) ^ <br /> r (D PLOT PLAN ON REVERSE SIDE) 711 N. Sacramento St. <br /> a FOR DEPARTMENT USE ONLY Lodi, California 95217 <br /> PHASE I - __. <br /># APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT=INSPECTION Y- . PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE. INSPECTION BY DATE �� <br /> E H 1426Rev. • -74 °177 2M <br />