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(Ja SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F 'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1_1/0z <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 G'l/G�GS t� CENSUS TRACT <br /> Owner's Name , /Yl 4'G`/2S Phone <br /> Address S` OA L, f Or-A�-1 4 4 u-C City 1AIA045a,t7 <br /> Said Joaquin Pump Co. <br /> Contractor's Name (Division of San Joaquin Sulphur Co.) License #�1� Phone <br /> 711 N. Sacramento St. <br /> Lodi, Colitarnia i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/Z:�P UMP REPLACEMENT /7 <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 <br /> PUMP .REPAIR: / State Work Done ��� d l&^4) 76 s- NP <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 GROUTINGFINAL INSPE $a11 Joaquin Pum Co. <br /> SIGNED ( TITLE q p <br /> WPLOT PLAN ON REVERSE SIDE) i; <br /> PHASE I FOR DEPARTMENT USE ONLY Lodi, California 95240 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIOIT Y PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <f. DATE "- 7" <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />