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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> POE OFFICE USE: 1601 E. Hazelton Ave. ,' Stockton, Calif. ' a <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 21710 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2- ( ] <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- Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION f 't'v'erdS�o� csr HWf';j2_/kjeaTaF• D4vil oao <br /> CENSUS TRACT <br /> Owner's Name E N S Ps r?t!C ' Phoneb� <br /> Address I-LIJ -'/2 City Z-0,0/ ` <br /> Contractor's Name 5ail �0 uan License #,716328 Phone. 2,4y7/ <br /> rte• <br /> TYPE OF WORK (Check) ; NEW WELL / /}DEEPEN / RECONDITION '/—/ DESTRUCTIN�/_J <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / 1) <br /> 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK < SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _._... OTHER <br /> � # <br /> PROPERTY LINE- f PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS T <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven- F ',,V -Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic'.Protection '.. Rotary Type of Grout <br /> DisposaOther Other Information �} <br /> Geophysical + <br /> . Surface Seal Installed_By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. " ` z r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / ..State Work Done i <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 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 notifythem before } <br /> putting- the in use.. . The above <br /> information is true to the best of my knowledge and. belief. I WILL CALL FOR A GROUT INSPECTION r <br /> PRIOR TO GROUTING IMAL NS <br /> SIGNED TITLE San .loo uin P' <br /> MD CA <br /> W PLOT PLAN ON REVERSE SIDE) "vision of Son Joaquin S <br /> FOR DEPARTMENT USE ONLY aacramento 5t, w <br /> PHASE I Lodi, Cafifariaia 9524( <br /> APPLICATION ACCEPTED BY DATE ( _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION I PHASE III/FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE z <br />-- E- H_1426 Rev. l-"7 4- 2M <br />