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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH~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 ,�g$(o gE p VR CENSUS TRACT <br /> Owner's Name U-4w z% tZlNOAOs j Phone 31-6CY- - 910 <br /> Address $-�-(� r9Cmtw.p .l�,e City e- 01,-),1 <br /> Contractor's Name SOA 70agUln Pump CO. License # 3'1038 Phone4 ._� <br /> TYPE OF WORK ,(Checks _ IE—WELL /� / DEEPEN_ f—/--RECONDITION /_/ DESTRUCTION / 7 , <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool - Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done eti s 41-!/ 1$/Z, <br /> i�{� 1�►�R Si a�E Cl ik L) <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 and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIZ AND A FINAL INSPECT <br /> SIGNED TITLE Son Joaquin Pump Co. <br /> og6n„ nf ';nn Inagviin Cnjphur Q-) <br /> RAW PLOT PLAN ON REVERSE SIDE) 711 N. Socramentg SL <br /> FOR DEPARTMENT USE ONLY Lodi, California 95240 <br /> PHASE I / <br /> 1 <br /> 'APPLICATION ACCEPTED BY DATE 1-2� <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I/FINAL INSPECTION <br /> 'PECTION BY DATE INSPECTION BY DATE , <br /> H 1426 <br /> �" / � . 6/77 . 2M <br />