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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave . , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,,Y�_ ) 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 9 a7Z$' <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 Lpwtje 5-O ,D CENSUS TRACT <br /> Owner's Name ' -.�'OSC Ott Phone <br /> 'Address 71 �[r�/ f City <br /> Contractor's Name Sang Joaquin Pump Co. License # �/3 w?,e PhoneX6 Y2f <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / f DESTRUCTION / `C <br /> _INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /� �Y <br /> PUMP INSTAL /[,./� _ Cn <br /> Other <br /> k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESPIT PRIVY <br />'f 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: Contractor <br /> Type of Pump c��i3r H.P. O <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done - <br /> FDESTRUCTIONFOF 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 /> f information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> (PRIOR TO GROUTING AN FINAL INSPECTION. San Joaquin Pump Co <br /> SIGNED TITLE <br /> (DW4 PLOT PLAN ON REVERSE SIDE) 711crnmpnto <br /> FOR DEPARTMENT USE ONLYLodi, Califarnia 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -- <br /> $%ADDITIONAL COMMENTS. <br /> PHASE II GROUT INSPECTION v PHASE III/FINAL INSPECTI0 <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M. <br />