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"- SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> FOF OFFICE USE: I; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ze 9_5? <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - Date Issued -7$' <br /> I�. (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!�Or inance No. 1$62 and._the. Rules and Regulations of the San Joaquin Local Health District.�v <br /> i JOB ADDRESS/LOCATION. ENSUS TRACT' <br /> Owner's Name Phone <br /> it <br /> Address K City A/ <br /> Contractor's Name aft �0{igU1n Pump CO. License ��30378 Phones <br /> ii f <br /> TYPE -OF RK (Check) : NEW WELL% /DEEPEN �/�/ RECONDTTIflN /�_ DESTRUCTIONS/-7° <br /> PUMP INSTALLATION / / PUMP REPAIR / / T PUMP REPLACEMENT /� <br /> I l —other <br /> F 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 li Cable Tool Dia, of Well Excavation <br /> Domestic/private _ Drilled Dia, of Well Casing <br /> Domestic/public -`Driven Gauge of Casing - t <br /> Irrigation ?! _; .` Gravel .Pack Depth-of Grout Seal- - <br /> Cathodic Protection Rotary . �-'" Type of Grout <br /> Disposal Other ` Other Information <br /> Geophysical h Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> !Type of Pump H.P.I— - - <br /> PUMP REPLACEMENT: / / State Work Done <br /> 's <br /> PUMP REPAIR: <br /> / / State Work Dane <br /> fDES•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 />(land 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 ofi! 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 GROU D A WINAL INSP San Joaquin Pimp �p, <br /> SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SIDE) `; 711 N. Sacramento St,_,' <br /> �j FOR.-DEPARTMENT USE ONLY -Lodi, Califmia _5.__ <br /> PHASE I <br /> APPLICATION ACCEPTED BY- DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE TIT/FINAL INSPECTI N <br /> INSPECTION BY II DATEINSPECTION BY , DATE <br /> t <br /> i . '/77 2M <br />'� E H 1'+26 -Rev. _1-7'4 - - _ <br />