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MV 'SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE QF ICE USE: Y 1601 E. Hazelton Ave. , Stockton, Calif. <br /> XlTelephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?-AIS'7 p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /f-tea-77 <br /> � (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> tand/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 - /�� �--- CENSUS TRACT <br /> Owner's Name <br /> M Phone j <br /> � <br /> Address 7 City G 4.0/ <br /> San ,Joaquin Pump o. <br /> Contractor's Name Division of Son Joaquin Sulphur Co.) License ��,3/(} ?�'' Phone a6 L-.Jy.:?/ <br /> 711 N. Sacramento t. <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN : ` � -- <br /> _ /1/ RECONDITION /__7 DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT 1_7 <br /> Other J-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY y <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, of Well Casing <br /> Domestic/public Driven ^4� <br /> Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic--,.ProtectionRotary Type of Grout <br /> Disposal , _ _.. _ _ Other. Other Information v <br /> Geophysical Surface Seal Installed By: V <br /> PUMP INSTALLATION: Contractor ,� `� Cor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / _State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i 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 t6 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 thewell 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 .I•NSPECTION. <br /> SIGNED - TITLE Son Joaquin PuMp Co. <br /> W Pi Di - .o T` PLAN 'ON RE�IERSE SIDE) uI941,Co <br /> PHASE I FOR DEPARTMENT USE ONLY Lodi, Colifarnia 95240 <br /> APPLICATION ACCEPTED BY DATE f- Z / 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE .II GROUT INSPECTION PHASE III/F / INSPEC'TI9N ` <br /> INSPECTION BY DATE INSPECTION BY DATE 7i <br />\Z..E H 1426 7Rev. 1-74 - _ .. I� ,,: , � �. 3/76 2M •:� <br />