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C"j6 SAN JOAQUIN LOCAL HEALTH DISTRICT x - <br /> FOS OFFICE USE: �}601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -101 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE "ISSUED ,. Date Issued. /, <br /> (Complete In Triplicate) krq - <br /> Application is hereby made to the 'San Joaquin Local l#e'nith District for a peimit to construct <br /> and/or install the work herein described. This application",:is made "in. compliance with San Joaquin <br /> County Ordinance Na. IS"62 and the Rules and Regulations of' the' San Joaquin Local Health District. <br /> JOB ADDRESS/,LOCATION $ t1 < V�, Is CENSUS TRACT <br /> Owner's Name ,Phaxae � <br /> Address_: " " 11z!ze2 ...... -,.- City , -Cj.YJ <br /> 50V1_y0aquin_ _UmpC0. <br /> Contractor" s-Name aF So License ## ] Phone 7� <br /> Lodi California. 240 <br /> TYPE OF WORK (Check) : NSW WELL DEEPEN /_7 PRECONDITION DESTRUCTION /7 <br /> PUMP INSTALLATIONS/ /. .PUMP REPAIR / IMP REPLACIIMNT <br /> Other <br /> .\ h. 77. \ <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/privateDrilled Dia. of Well Casing <br /> Domestic/public .._._..... Driven Gauge of Casing q <br /> Irrigation v Gravel Pack Depth-of Gout Seal, <br /> Cathodic -Prote"ction - Rot&r-y-_-Type off-Grout - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'By _ <br /> PUMP INSTALLATION: Contractor . i <br /> Type of PUMP , H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP 1tEPATRr /L{--°State Work Done /-Ydk/11, a_ - 90 <br /> TIES-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 them before putting.the..well- in.use.... .The above <br /> information is true to-the beet-of. my..knowledge and belief. I WILL CALL:FOR,A GROUT INSPECTION <br /> PRIOR TO GROUTI AND A FINAL INSPECTIO - $ daquin -pumpad. <br /> aD , - <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE -71sIOn 0,1,"fl <br /> FOR DEPARTMENT USE ONLY Lodi,.California 95240 <br /> PHASE I n r <br /> APPLICATION ACCEPTED BY . DATE ' /0 '/S' <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III FINAL INSPECTI N <br /> INSPECTION By DATE INSPECTION BY DATE.• <br /> k E H 1426 Rev. 1-74 rr. `_ 475 2M <br />