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a SAN JOAQUIN LOCAL HEALTH DISTRICT Y v �Jr o <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <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, � <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 I' 7 J — - /N4faEe O&Z42g CENSUS TRACT <br /> Owner r s Name 0 4F=— A, % Phone s�� ^ • y�7� <br /> Address _ f 4 City <br /> Son Joaquin Pump Co. <br /> Contractor's Name (Division of San Joaquin Sulphur Co.) License <br /> 711 N. Sacramento St. _ <br /> Lodi, a j arnca 95240 ` <br /> TYPE OF WORK (Check) : NEW WELL E7 DEEPEN_ /_/ ,RECONDITION /_/ ._DESTRUCTION„/� <br /> PUMP INSTALLATION / / PUMP REPAIR /t.�VUMP REPLACEMENT— <br /> Other <br /> EPLACEMENT <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 (A <br /> INTENDED USE TYPE OF WELL - CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing N; <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 Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <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 /> --� <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 wel1"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 m knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO D A FINA SP ION. Son joaquin rump Co. <br /> SIGNED TI'T'LE (Division of San Joaquin Sulphur Co.) <br /> (DRAW PLOT PLAN ON REVERSE SIDE) acramerito St. <br /> 4.1 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �e,j~ DATE L/2` !� rte° 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. - 1-74 <br />