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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 /> APP ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� 7-2O /0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,�_� <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 &FAL P Ri 5 -1110, ,lf v e S,gle&W CENSUS TRACT � <br /> - f <br /> Owner's Name , ei f Phone <br /> _ <br /> Address Cit.� � .. / Y Go/J/ - <br /> Contractor's Name Son Joaquin Pump Co. License # 63) Phone _1f0 <br /> !Division of 5an Joaquin <br /> L <br /> CCaii aQ_95240 <br /> TYPE OF WORK`(Check)i�"NEW *I,L DEEPEN 'RECONDITION-/7-�DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / UMP REPLACEMENT /? <br /> Other <br /> T <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES PIT PRIVY <br /> F 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 Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout. <br /> Disposal- `• _Other.. _...m Other .Information _ <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 7-1"e Al-Tiggr <br /> PUMP .REPAIR: /;;/!State Work Done & % wd u A,.[1 `G'� O 6�e 7Zi e_13lt1 <br /> DESTRUCTION OF WELL: We11: 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 GROUIRM AND A FINAL INSPECTIO Spro Joaquin Pump I;a <br /> I SIGNED ar TITLE <br /> I]RAW PLOT' RE ERSE SIDE <br /> FOR DEPARTMENT USE ONLY Lodi, California 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYtaC.w DATE t - 1--77 <br /> a <br /> � 3/76 2M <br /> E H 1426 Rev. 1-74:... <br />