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SAN JOAQUIN LOCAL HEALTH DISTRICT k <br /> FOR OFFICE USE: 7 AD 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 27- EZK <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued sa3-J� <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 /> J-o3 / <br /> JOB ADDRESS/LOCATION - � CENSUS TRACT <br /> Owner's Name k0A.0O s1 L e- <br /> Phone 36 S—6,93 <br /> 3 <br /> Address fV• city G U .o/ <br /> Sart Joaquin Pump a. <br /> Contractor's Namenn Joaquin Sulphur C.O.) License VPhone Ay7of 5 / <br /> 1 N. Snzrarnento i <br /> Lodi, Ccs2< o.rp,a <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN -/ I RECONDITION_ DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR // UMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES " PIT PRIVY <br /> SEWAGE DISPOSAL FIELD .x— CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL p <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS a <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: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br />! PUMP .REPAIR: /State Work Done A%lf AtC <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 wel.l'coristruction. 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 GROUTI FINAL NSPE San Joaquin Pdatttp Co: <br /> TITLE <br /> SIGNED <br /> W 'L ' PLAN ON REVERSE SIDE} owsian o cq'Zq <br /> au¢n 5jc o. :. �`• <br /> FOR DEPARTMENT USE ONLY Lodi, Califmrsiia 95240 <br /> PHASE I r. <br /> DATE <br /> APPLICATION ACCEPTED BY 99= /tel'- 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY C� DATE <br /> 3/76 2M <br /> R H 1426 Ray. 1—'74 <br />