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SAN JOA4UIN LOCAL HEALTH DISTRICT a <br /> FOEFF <br /> OICE USE: 11601 E. Hazelton Ave. , Stockton, Calif. ; <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No." LAS <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 J /q� 112 r//o WyouPo2rA[.t; •v �o�2,Ps Z4.41 CENSUS TRACT i <br /> Owner's Name S Phone <br /> 2� City <br /> Address i HCl , 17P. V f2 r _ ' <br /> Contractor's Name San ]onqum Pump Co. License #3&3Z9 Phone _'- <br /> (Division of San Joaquin u p ur a. -�=t <br /> TYPE OF WORK (Check) : jaj� tyr'iy-�24tEEPEN / / RECONDITION DESTRUCTION <br /> PUMP INSTALLATION ltKPUMP REPAIR '/ / PUMP REPLACEMENT <br /> Other / / <br /> 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 i' TYPE OF WELL ! CONSTRUCTION SPECIFICATIONS <br /> Industrial i. Cable Tool Dia. of.,Yell Excavation <br /> Domestic/private Drilled Dia. of W611 Casing �R <br /> t Domestic/public Driven t ,4,,Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ; <br /> Disposal _; 'v ! + Other.. Other Information <br /> Geophysical Surface Seal Installed By: <br /> sl n <br />' PUMP INSTALLATION: Contractor i.,.J Yc t Ca <br />?, Type of Pump & H.P. f o _ <br /> PUMP REPLACEMENT: . �I State Work Done <br /> PUMP REPAIR: l � <br /> !� 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'2best of my.-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> ' PRIOR TO GROUTING .AN INAL INSPECTION. San Joaquin Pump Co. <br /> SIGNED TITLE <br /> R!E&KOT PLAN ON---:REVERSE SID <br /> FOR DEPARTMENT USE ONLY Lodi, :alifarnia 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE rj7-�_�2 <br /> ADDITIONAL COMMENTS: !I <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 0` DATE 9Y-7 2 <br /> I <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br /> I� , <br />