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p f w SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> FOF,fOFFICE USE: <br /> - 1601 E. Hazelton Ave. ,. Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued F <br /> (Complete In Triplicate) <br /> Application `is lierelay_ 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 Regulate?ons of the ,San 'Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 5 'U C&S'F Y C it ptet/ CENSUS TRACT", <br /> c Phone a �; <br /> Owners Name <br /> Address epi 01,2,0 ° City.;.. <br /> an joaquinyump <br /> Contractor's Name (Division of 50n Joaquin Sulphur Co.) License # ° Phone <br /> . .. 71.1 N. Sacra <br /> Mcnvu St. <br /> TYPE OF WORK (Check): NEW WELL -/-7 DEEPEN /-7 RECONDITION %T DESTRUCTION f7 <br /> PUMP INSTALLATION ]PUMP REPAIR/_7 PUMP REPLACEMENT 17 ' <br /> Other70 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD a CESSPOOL/SEEPAGE 'PIT OTHER Q <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL , <br /> , INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �y <br /> Industrial Cable Tool Dia. of Well Excavation n <br /> iDomestic/private Drilled Dia. of Well. Casing _ _ -- <br /> " Domestic/i4iic Driven Gauge of Casing <br /> t Irrigation Gravel Pack- Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other. Information. <br /> Geophysical f Surface Seal Ihstalled_By: <br /> PUMP INSTALLATION-. ' Contractor . !_l <br /> Type .of Pump r H.P. <br /> E PUMP REPLACEMENT: / / State Work Done, <br /> PUMP :REPAIR: / // State Work Done <br /> DESTRUCTION OF WELL: Well Diameter -Approxcimate 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 INSPVCTIO ' . <br /> SIGNED TITLE Son. Joaquin Pump Co. <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> k FOR DEPARTMENT USE ONLY Lodi, Ca'ifarnia 95240 <br /> PHASE I f} <br /> APPLICATION ACCEPTED BY DATE 7 d . <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONnz <br /> PHAS II AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ` <br /> nrn �ew� rr 1�/7c� 2M <br />