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. SAN JOAQUIN LOCAL HEALTH. DISTRICT ! <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 1 (Complete In Triplicate) 0� <br /> A <br /> pp ication 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.,1.862, ind the-Rules and Regulations of the San Joaquin Local Health District. <br /> JO$ ADDRESS/LOCATION - eseg -- CENSUS TRACT <br /> Owner's Name o Phone <br /> Address City <br /> Contractor's Name Sen Joaquin Pump Co. <br /> License # 637�'Phone ' <br /> (MVISIGH Of SUkI jZ044ill 5".19,11M C00 - <br /> Lodi--Cca"1, 95240_ _ _ <br /> TYPE OF WORK (Check) : NEW WLL / DEEPEN % / RECONDITION /_7 DESTRUCTION / - <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT / d <br /> Other '/_7 <br /> .. <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; •Grbut <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor'- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /_"4___S Done es/(�'C'� 3 ��.l� GJ r�� �r !�{� ScAll <br /> PUMP "REPAIR: - /-7 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 weli'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 myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU A-FINAL INSPECTION. e< <br /> TITLE San Joaquin Pp Co. <br /> SIGNED <br /> DRAW L T PLAN 'ON REVERSE SIDE - °p �a►Co.) ` ' ' <br /> FOR DEPARTMENT USE ONLY Lodi, Califurnic 9,52'" I <br /> PHASE I40 <br /> APPLICATION ACCEPTED BY DATE J- I3-�? k <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE TTI/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _�` +� DATE /1 -/ .77 <br /> E H 1426 Rev. 1-74 — 376 2M <br />