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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1/1601,. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ,466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;6._a 97p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,57.Al-76 <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 / dl ft*I ..t7 c 1V' & ne4,OeCENSUS TRACT <br /> Owner's Name _0 'e) /a(5 A,).&67&- Phone <br />'I` Address _ /7 0el6_S City 6001 <br /> Contractor's Name San Joaquin Pump Co. <br /> Sulphur Ge.) License �� Phone36 <br /> G.. ❑p 0 <br /> Lodi <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION <br /> PUMP 'INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> t SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> F <br /> INTENDED USE' 'TYPE OF WELL 4 A Y CONSTRUCTION SPECIFICATIONS \ <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 i Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> E PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: _ /l./'�State Work bone 1U �� „__-leL i rs�d t�XlSAy 4je l <br /> x \ <br /> PUMP REPAIR: / / State Work Donet- <br /> ,DESTRUCTION OF WELL: Well :Diameter s ' 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 of 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. <br /> ---/- San Joaquin Pnsyp Co. <br /> SIGNED / ! TITLE (Division of San Joaquin Sulphur Co.) <br /> (DRAW PLOT PLAN ON REVERSE SIDET 711 N. Sacramento St. <br /> j FOR DEPARTMENT USE ONLY Loal, t,amarkt a 952. <br /> PHASE I i r <br /> APPLICATION ACCEPTED BY 1 € <br /> DATE <br /> ADDITIONAL COMMENTS: ''' <br /> PHASE II GROUVINSPECTION PHASE I I F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE DP74 <br /> CALL FOR A GROUT. INSPECTION PRIOR TO GROUTING. AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />