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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE:i�d1601 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 <br /> .SC� S�A-c-r (Complete In Triplicate) _ <br /> Application is hereby made to the San Joaquin Local Health District for a perrmi -to c 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 SuL� ~� fScc�is�7i�G� U 5 of F2CFfun} <br /> CENSUS TRACT _ <br /> Owner's Name ' R c �N AJ Phone 362- /9�7L '. <br /> _ <br /> Address 9.S / C lzScl� �cl�1'1F1n) f�e� �� <br /> - City <br /> San jcn,-° � ..��e- 1p -0. <br /> x:i <br /> Contractor's Name , f s, f.n , -. ',�SU7 co,) License # <br /> 1 N. S.�rcmc,--:'a �t. �� Phone 3G�!J �1"7 <br /> Lodi, C;aiiso.ra:a ���Sia <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /_/ RECONDITION /7 DESTRUCTION /_7 T <br /> PUMP INSTALLATION / / PUMP REPAIR -_PUyp REPLACEMENT /_7 <br /> Other /% — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELT, 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 /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /State Work Done <br /> k !7 - J7411-C <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ------ <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. <br /> SIGNED t J e`ix ' TITLE San ��W ii 1' r p co, <br /> (DRAW PLOT FLAN ON REVERSE S IDE - c <br /> PHASE I FOR DEPARTMENT USE ONLY Lodi, Ca ifarnia 93240 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/F4,NAL INSPEC I <br /> INSPECTION BY DATE INSPECTION BY DATE b <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION <br /> E H 1426 <br /> 7/72 IM <br />