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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP-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 /> �1 Zo? �: rfJA - f1 °rJ: tI_25c�_2g <br /> JOB ADDRESS/LOCATION 1V0._r11 ,g Du.v!� f311 kc�CENSUS TRACT ' i <br /> Owner's Name 2_ ^' > c� ,e Phone ��7- 1/r <br /> Address City 6/,rJ,0c5A1 <br /> Contractor's Name Son haguin Pump Co, -~ <br /> License # _ � s, hone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY CIP <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 X 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: /i.?"'�S tate Work Done 20-"_W, <br /> PUMP .REPAIR: / / State Work Done '�✓' 4 <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 'constructi.on. 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 thewell 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 G G AND A.FINAL_ULUEC ��' <br /> SIGNED ) s TITLE Son Joaquin N-13P <br /> _- (DRAW PLOT PLAN ON REVERSE SIDE)(Division a an Jou <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ! , Lodi, California 95240 <br /> APPLICATION ACCEPTED,, s DATE <br /> i <br /> ADDITIONAL COMMENTS: <br /> PHASE- : GROUT'°INSPECTION PH41V III/ INAL INSPECTION <br /> INSPECTION BY —T ?' DATEINSPECTION BY DATE 7 <br /> E H 1426 RP,17_ , 1.71A 6/77 _ 2M <br />