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SAN JOAQUIN LOCAL HEALTH. DISTRICT , . <br /> FOR 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 y�-��-77 <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 1 mss /�/�,� _ __ CENSUS TRACT <br /> Owner's Name __ QN-- - .tJ. ;�P C_ -- --- Phone _7 _ s6 p <br /> Address /r ' `S C/G /�/G�E' city n/PL Pea <br /> — --- - -- <br /> Contractor's Name San Joaquin Pump Co. License 3)03Zk Phone — v7 <br /> r,. - .. <br /> i <br /> Lodi, 3lifamia 95240_ - <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION-/—_7-- � <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / : PUMP REPLACEMENT /�� <br /> Other <br /> i <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 /> NI <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge .of Casing <br /> Irrigation Gravel Pack Depth of Grout Sial -- <br /> Catlf6dic' Pio tectiori' "` - " 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 r i�S rte!// �4() <br /> 1• <br /> PUMP -REPAIR: / / State Work Done 6 <br /> _ 3 <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 G G AND A FINAL INSPECTIOW Son Joaquin Pump^Co. <br /> ^ <br /> SIGNED TITLE <br /> (DRAW P T' PLAN ;ON REVERSE SIDE 11 :I,bi <br /> !' <br /> FOR DEPARTMENT USE ONLY Lodi, Coiifamia 95240 <br /> PHASE I € <br /> APPLICATION ACCEPTED BY ;, DATE - Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS II FINAL INSP TION <br /> INSPECTION BY DATE INSPECTION BY v/ DATE <br />- - E H 1426 Rev. 1-74 .. , . <br /> 3/7b 2M <br />