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SAN JOAQUIN LOCAL HEALTH DISTRICT R / <br /> F F"OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-8-Yo✓j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued It-all <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 �4i, S j �_ � c%/dam G � �_ _ CENSUS TRACT <br /> Owner's Name „ Phone 2M V0.0 <br /> Address ------- i1 <br /> City Z-0,0 neon rump%%U. / <br /> Contractor's Name (Division of Son Joaquin Suip'aur Co.) License Phonee3 f <br /> 711 1j. sucianlenle <br /> 2-40 <br /> TYPE OF WORK (Check) : NEW WELL J J DEEPEN/ / RECONDITION /—/ DESTRUCTION /-7— <br /> PUMP <br /> - —PUMP INSTALLATION / PUMP REPAIR J / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 <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 _ �', f}/ Q u.t J �CL <br /> Type of Pump %Ce e.C3l,v : H.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 GROUTING AND A FINAL INSPEC N. Sorg Joaquin Pump Co. <br /> SIGNED f— TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) 71n <br /> FOR DEPARTMENT USE ONLY Lodi, California 957; <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE .F <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> /7 _ 2M <br /> E H 1426 Rev. - I-74 , <br />