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.:' SAN JOAQUIN LOCAL HEALTH DISTRICT Al <br /> FJ)~ OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. �������� <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued f�7- 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 Rule and Regulations of the San Joaquin Local Health District. <br /> �1,�3� <br /> JOB ADDRESS/LOCATION S rE � GS Sau7W s, .0 z j,�,�,e .�r�'CENSUS TRACT <br /> i <br /> Owner's Name L ,A_1 ^T4 r Phone ;KGj=Ci,0 38 <br /> Cit L G 0 <br /> Address 14 3 - Y <br /> Contractor's Name Stirs lnaarvin Pomp Co. License # fQ Phane��9 7/ <br /> s <br /> . I <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /77 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES _ PIT PRIVY w <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 <br /> :PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /+- State Work Done ` � Q u f <br /> I <br /> DESTRUCTION` OF WELL: WellDiameter APFroxi:inate' 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 thewell 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, L INSPECTION TITLE Sass Joaqum Pump Co. <br /> SIGNED o <br /> M DRAW PLOT AN OR REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY Lodi, Colifo.rnia 95240 <br /> PHASE I � DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FIN INSPECTION <br /> l INSPECTION BY DATE INSPECTION BY - DATE , <br /> 6/77 2M <br />