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SAN JOAQUIN LOCAL HEALTH DISTRICT r ' <br /> FCS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ,,.,. Telephone: (209) 466-6781 �5� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, �� 2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued T4.2d-/d- <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 Jos, uin Local Health District. <br /> 6�s r o A /o 2 s' 0 f+�.r7 ed wG � <br /> JOB ADDRESS/LOCATION OF d,4,A_x*,k 114=Ck, t 4j F e tz I<1 CENSUS TRACT <br /> Owner's Name _ _ skAu R ie-.,e- 1-<aAeL4 LLo(2_ Phone 52A 9- 24 I�Q <br /> Address 4±5- 0V/—�S72nP—rWI City Z�_Lyd <br /> Contractor's Name Sap Joaquin PMD CO. License # 3/0"Phone �� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN `/_/ RECONDITION /_7 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 O <br /> INTENDED USE TYPE OF WELL _ - CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation N` <br /> Domestic/private Drilled Dia. of Well Casing �R <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: qq <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Z� State Work DoneT® � ey <br /> PUMP .REPAIR: / / State Work Done �'.�31-!/moi <br /> — <br /> DES•TRUCTION 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 puttingthe well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT IN N <br /> PRIOR TO GROUTING FIN <I SPE <br /> SIGNED TITLE Sap Joaquin Puinp Co. <br /> ( PLOT PLAN ON REVERSE SIDE iwawn o an loogcsin Suip,�Ur ci.) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Lodi, Califarnia 952 <br /> APPLICATION ACCEPTED BY X� DATE Z 7 - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPEC I <br /> INSPECTION BY DATE" INSPECTION BY DATE <br /> 6/77 2M <br /> E H 1426 Re_ . � 1-74 , <br />