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SAN JOAQUIN LOCAL HEALTH DISTRICT 01 <br /> FOE OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781. _ <br /> + APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, p <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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health-District. <br /> JOB ADDRESS/LOCATION _ Leet CENSUS TRACT <br /> k Owner's Name /-�kjgPf 7 h/ a-00lUY Phone _ <br /> Address City 4L—v.c� <br /> . Contractor's Name San Joaquin Pump Co. License #3/037 Phone <br /> .1. TYPE OF WORK (Check) : NEW WELL / / DEEPEN /% RECONDITSON / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/.SEEPAGE PIT _ OTHER 1 <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _Cable Tool Dia. of WeIT avation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary . �7 Type of Grout <br /> Disposal Other LN Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor` <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 1-:;T'S tate Work DoneA�_4,42 AIYO <br /> PUMP REPAIR: <br /> / / State Work Done <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 <br /> rict <br /> and the State of California pertaining to or regulating well construction . Within FIFTEENDAYS" 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 AN FINAL INSPE Tl <br /> SIGNED TITLE San Joaquin Prim Co <br /> (D PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY'. Y„ A��` n r St <br /> PHASE I Lodi, California 95240 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE <br /> E H 1426 Rev- 1-74 n�77 - 2M <br />