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� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR_;'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. L <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 xs 19,,8 <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 Gel esoo :43.e/.D 6 +C CENSUS TRACT <br /> Owner's Name R k C �r Phone <br /> Address:. f CSX City W)A7,0727CIq <br /> XC <br /> Contractor's Name San .Torre+�ra�l sarrlr9 Co. License j#�Z?I13, fPhone _&_ � <br /> 'i 1 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPENRECONDITION / / DESTRUCTION /_7 Cd'� <br /> PUMP INSTALLATION / 4?' PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / d — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ICESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL )kCONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, fWell Excavation <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 Type of Grout <br /> Disposal - 'Other Other Info mation IA' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor . <br /> Type of Pump - :+6s H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / 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 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 nd 'belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTINGAL IN ECT - San Joaquin Pump o. <br /> SIGNED TITLE <br /> (Division of San Joaquin Sulphur C46) . <br /> (DRAM OT PLAN ON REVERSE SIDE) 711 N. Sacramento St. <br /> OR DEPARTMENT USE ONLY Lodi, a ► arena .) <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE " ~ i <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI N PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z- --_ <br /> E H 1426 Rev. - 1-74 <br /> 0�%7 2M <br />