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SAN JOAQUIN -LOCAL HEALTH DISTRICT <br /> F0� OFFIC US ; 1601. E. Hazelton Ave. , . Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ']�r�] <br /> F <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuad;2 <br /> I (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 he Rules and Regulations of the 'San Joaquin Local.' Heal,th District. <br /> JOB ADDRESS/LOCATIONF�Sr 5'10e arm/cs, AuortTN rr ,oVc,TiGCENSUS TRACT <br />' Owner's Name K La. C-7 11q e- Phone ,36�g- <br /> Address oc.J 5 f0— D City /5 e�9l�t Pct <br /> Contractor's Name 5ain joiuiraPump Co. License Phone -_ � <br /> I � <br /> -TYRE-0 F WORKS (Check) :ANEW=WELL•'�/ DE'EP•EN-/-�/-RECONDITION-/-/—DESTRV CTION-/ "-��"�-� <br /> AL <br /> PUMP INSTLATION I.,I UMP REPAIR / / PUMP REPLACEMENT /� W <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 C � <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/publi.e, - Drivens _ _ Gauge-„of Casing _ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic :Protect ion 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 C <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> �� Approximate Depth <br /> Describe Material and. Procedure <br /> 7 <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District J <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 puttingthewell in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPE TION 1 <br /> PRIOR TO GROUTING AND A FIN I PE9 N. _- San Joaquin Pu!-np Co. <br /> SIGNED TITLE rnv�cinn of Son Inn iin 1 <br /> (DI &P :: <br /> PLAN ON REVERSE SIDE) 711 N- Sasxgm,euta St_ <br /> FO <br /> PHASE z DEPARTMENT USE ONLY Lodi, Caii'rarnia 95240 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: j , 7 1��J <br /> PHASE II GROUT INSPECTION J PHASE 7_II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 24 7'F <br /> E H 1426 Rev. � 1-74 n!77 2M <br />