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SAN IOAQUIP LOCAL HEALTH DISTRICT <br /> FOF_ OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> V I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7�- IXk <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued lLallw <br /> . <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 f L,,20 ,, �l�f?� �+,1�Qi3,E�/,Q� CENSUS TRACT <br /> Owner's Name e2- ti.0 Phones �'lj"?1J�_ <br /> Address �� � r'l�lJ7�9 Cityf)DUl��C'� <br /> Contractor's Name son jmn t :' License #316-3 Phone,.?] __'.�7 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN%/ RECONDITION AL / /-7—/ DESTRUCTION / _ V <br /> PUMP INSTALLATION /.: 'UMP 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: Contractoriil�J Tag gxfr� >,O <br /> Type of Pump I�L,E'C3/.t1 H.P. 7 Z _ <br /> PUMP REPLACEMENT: / / State Work Done <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 GROUTI A FINAL IXSzO <br /> SIGNED TITLE San Joc qut , P"a- p CO. <br /> RAW PLOT PLAN ON REVERSE S IDAjvision of Son jocqum Sul p,uro. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Lodi, Caltornia 9520 (/ <br /> APPLICATION ACCEPTED BY 1g, DATE <br /> ADDITIONAL COMMENTS: 01 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTJOIJ <br /> INSPECTION BY DATE INSPECTION BY w DATE I/ <br /> 2M <br /> E H 1426 Rev. - 1-74 <br />