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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE�•OFFfCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. a <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- 3��10111 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,r6-77 <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 > !`T"' ;e < ., 4J v P ! s CENSUS TRACT <br /> Owner's Name , d� Phone O 4/02 <br /> Z - <br /> Address J /l OJ, UXA-1C - E i:> City 0,0� <br /> San Joaquin Pump Co. License # 2163ZIPhone '�69-�' 7 <br /> Contractor's Name _, quinhur CO.) <br /> mento St. i <br /> of rria 9524t] <br /> TYPE OF WORK (Check) : NEW WELL f T DEEPEN/ RECONDITION DESTRUCTION DESTRUCTION /=T <br /> PUMP INSTALLATION / UMP REPAIR/ / PUMP REPLACEMENT /� <br /> AL <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY O <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 B : <br /> PUMP INS7:ALLATION: Contractor .t) DC! <br /> Type of Pump ,� e H.P. p `� <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 GRQ=ING AND A FINAL INSPE ON. j Sun Joaquin Primp Co. <br /> SIGNED _ TITLESan - <br /> D W PL PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY Lodi, Galifarnia 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BY /` (J DATE 31 L2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I/,FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ;-L-=,7-7 7 <br /> E H 1.426 Rev. 1--74 <br /> . . 3/76 2M <br />