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i <br /> SAN J'OAQUIN LOCAL HEALTH DISTRICT <br /> FOR;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ` <br /> a <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. zS 3;� . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <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 Regulationa of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION (yO IF-Ast.e_ i CENSUS TRACT ZL <br /> Owner's .Name Phone 'ms V­ - 5 da <br /> Address A ! 3 `J City ._L,.� b <br /> Sari Joaquin-Pump CO. <br /> Contractor's Nana San Joaquin Sulphur Ca.i License # Phone <br /> Kettleman <br /> Lodi, Caffornia V�L4U - <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN '/? RECONDITION /_7 DESTRUCTION F <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /7 <br /> Other /J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY n1 <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 INSTALLATION: yContractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> E PUMP :REPAIR: / / State Work Done Lu L - P Q rye u,4� r;'a t s�� .i ,c rG ��' A ( t <br /> DES-TRUCTION 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 /> I 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 GROUTING AND A VININSPECTION. TITLE San 3oaquin pump Co <br /> SIGNETS .i <br /> iLc1 c_ <br /> (DRAW PLOT PLAN ON REVERSE SIDE eman <br /> CAa7Y �c�2 �yS�Pr-.%/dam✓ FOR DEPARTMENT USE ONLY L,0dii Ca <br /> 4ifamia 9524 <br /> PHASE I <br /> � APPLICATION' ACCEPTED BY DATE CZ— 72 <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTTON PHASE III FINAL INSPECTION <br /> INSPEC'T'ION BY DATE INSPECTION BY DATE o <br /> h/77 c4m- <br />