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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB:OFFICE USE: 11601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: _ (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76 yip <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 ,Z7-76 <br /> (Complete In Triplicate), <br /> Application is hereby made to the San Joaquin Local health Digtrict' for a permit to construct <br /> and/or install the work herein described. This application is inade'.in. compliance With San Joaquin- <br /> County Ordinance So. 186 and t ' Rul Pd Re u1 tios � tee San -Joaquin Local Health District. <br /> los-,E_� C_f4�o 1�/ i <br /> JOB ADDRESS/LOCATION S CENSUS TRACT /3Z-070-/0 <br /> ' <br /> Owner's' Name } ,J =r 1L ' ` Phone - — 3 c 7 <br /> Address 3 Z 63 N "`12ULCE s City' "57 Te n <br /> Contractor's Name a19 :9oagtPIVIS1011 Of l j0 Pump 0140111 SUMP!a 0 License U-M 7 Phone GZ:�'`��� <br /> TYPE OF WORK (Check): NEi WELL / DEEPEN "/7 RECONDITION DESTRUCTION /_T' <br /> � <br /> PUMP INSTALLATION 1 PUMP REPAIR-Ig PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY UQ <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 Dia:•:o€ Well Casing <br /> Domestic/public W..r..___ 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 'B <br /> PUMP SNSTALLATIONo. Contractor <br /> Type of Pump ' H.P. <br /> PUMP REPLACEMENT:' / / State Work Done <br /> PUMP 'REPAIR: /1; State Work Done ELK / <br /> RES-TRUCTION 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 theta 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 <br /> SIGNED TITLE San Joaquin Pump Co: .� <br /> DRAW PLOT PLAN ON REVERSE SIDE (Division of Son Joaquin Sulphur Co.) <br /> FOR DEPARTMENT USE ONLY ac a. <br /> PHASE I Lodi, California 95 40 <br /> APPLICATION ACCEPTED BY DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT MSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rav_ 7_7G r' 1./7C 9wt <br />