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t - <br /> SAN JOA UIN LOCAL HEALTH DISTRICT <br /> FOk,-OFFICE USE: 1601 E, Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> lutf APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7 <br /> gEC 2 2 1977 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date ,Issue <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. 1.862 and the Rules and Regulations of. the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S /i't,/e N/a /'�CCt►�,[_ o i s to_a 09—ki &68 CENSUS TRACT � <br /> Owner's Name �, Phone <br /> Address .1•Z,/0.9_,.., _—.,E? rPLlt��-1/3 _ City Q goo <br /> Contractor's Name Son 700auln Pumn C•o. License 11 316378 Phone :jgk:�/=jV7/ } <br /> TY.P_E_OF,WORK (Check) : L <br /> NEW WEL / /'`'DEEPEN /T//'` RECONDITION / / DESTRUCTION 1-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIKES 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 O <br /> Domestic/public Driven Gauge of Casing �{ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of ,Grout a. <br /> —Disposal- - - Other Other Information <br /> Geophysical Surface Seal. Installed By: , <br /> - - I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump t H.P. _— <br /> a <br /> • F <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 />'r 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 i <br /> WELL DRILLERS REPORT of the well and notify there before putting the. well in use... The above <br /> information is true to the best of. my knowle ge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO AND A FIN A I Sass 1oa uin Pum Co. -4� <br /> SIGNED TITLE P <br /> RAW PLOT PLAN ON REVERSE SIDE) n aaquin u p ur <br /> V. <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY Lodi, Califarnia 95140 <br /> APPLICATION ACCEPTED BY�� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE _ INSPECTION BY DATE (L, -""t� <br /> 61/77 . 2M. 1 <br /> E H 1426 Rev. , 1_74 <br />