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_ W 'SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F'OFF OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.MV <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 S <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 41 49 9 _.t� -Za(A E LLA T CENSUS TRACT � <br /> Owner's Name Z�V�.nl.,G ��� qMg Phone 36q- 2397 ! <br /> t <br /> Address <br /> a2 `f CJ l\ pz)q1 "CCX n City nq U t <br /> Contractor's Name ��� � � �cav�o CO. License #,3103ZB Phone 0411/ <br /> •y <br />-T=YPE-OF-WORK (.Check) :--;NEW. WELL-/�/- DEEPEN /_/—RECONDITION .-/_/, -.. T <br /> DES .RUCTION-/�T, <br /> "PUMP INSTALLATION / / PUMP REPAIR / 'UMP REPLACEMENT <br /> A, Other <br /> DISTANCE TO NEAREST: SEPTIC TANK c- ,, * . SEWER- LINES PIT PRIVY T <br /> SEWAGE DISPOSAL FIELD :" CESSPOOL/SEEPAGE PIT OTHER 'C� <br /> PROPERTY LINE - PRIVATE-DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I'f <br /> Industrial. Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing Q <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 /> I4 PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /� State Work Done %s 91il/� <br />$DES-T.RUCTION OF WELLW: T � Well Diameter Approximate Depth <br /> x 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 GROUTIN A FIN Af INSPE N. <br /> Son Joaquin Pimp Co. <br /> SIGNED TITLE (r%W9$4^n of Sal; j9eqH1R <br /> W PLOT PLAN ON REVERSE SIDE) YSt <br /> FOR DEPARTMENT USE ONLY Lodi, California 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Z� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIM PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE s <br /> 7—/2of77 2M <br /> t. <br /> 1-74 <br /> E H 1426 Rev. • '- <br />