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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 (� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 � ('r <br /> VY <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> s" VV '1.0-00 E- 0. (Complete In Triplicate) 0[-3 — (40-3fApplication 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 Noo./f 2 and the Rules and Regulations of the San Joaq in Local Health District. <br /> 0,d, tJP57 of 40tvc2 Sracro ,Zo Ta /WAY Zisl Altsa7W 7-,0 <br /> JOB ADD SS/LOCATIO )2opC Ili] wps7" o E.u.o eF r-oAp CENSUS TRACT <br /> Owner's Name o a q an„/E phone 348 — oii4.0 <br /> Address 73 8 {_j A M Lr\ NI Q City 4-001 <br /> Contractor's NameSMjjpair€n Pt!rAn fin. 3Wjl 3kj��13 <br /> License �� Phane <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /—/ DESTRUCTION /_7 �. <br /> PUMP INSTALLATION / / PUMP REPAIR / / 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 <br /> Type: of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done Ince ..-p,�SQ.j T _�ey we ry,fiy A0�1'lr�.�� <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 FI EEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Heal District a <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use. The bIbve <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT I S ECTION <br /> PRIOR TO GROUTI A FINAL INSPE N . <br /> SIGNED TITLE San Joaqu*n Pump C .I <br /> --Lpj�S;�ryr�ff i..�.,..:., l..1 wr Ce.9 <br /> RAW PLOT PLAN ON REVERSE SIDE)PHASE I �T <br /> FOR DEPARTMENT USE ONLY Lodi, Colifarnia 95240 <br /> APPLICATION ACCEPTED BY P DATE <br /> ADDITIONAL COMMENTS: 7 jr <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE L <br /> b/77 2M <br /> E H 1426 Rev. - 1-74 <br />