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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR„OFPICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: :: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;7Z- 5iLp <br /> THIS PERMIT. EXPIRES 1 YEAR FROM DATE ISSUED.. - Date Issued <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 /> 5406- G� <br /> JOB ADDRESS/LOCATION , F jV,pjCS ,,,v 11,Wk--/Z -CENSUS TRACT <br /> Owner's Name 6?.eG�S �Y.v . /.� t L Phone <br /> Address / i Z City G p,0 / <br /> Sanloaquln Pump <br /> Contractor's Name 03� Phone�49A7/ <br /> (DwwnnSulphur <br /> Co License C ��Y31 <br /> 11. N. Sacramento St. <br /> . i_odi, Caiifo.rnia 95240i <br /> _ _ e <br /> TYPE OF WORK (Check) : NEW WELL ./7 DEEPEN / / RECONDITION / / DESTRUCTION /'7 <br /> PUMP INSTALLATION/ / PUMP REPAIR%�PUMP REPLACEMENT /_7 <br /> Other /_7 <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 We11 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 INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . /_7 State Work-Done <br /> PUMP .REPAIR:- _ e� j,. State Work Done <br /> s DES-TRUCTION 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 notify them before putting the,.well in use. The above <br /> information is true to the best of my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION i <br /> PRIOR. TO GRO ING AND A FINAL INSPECTIO F <br /> SIGNED TITLE San Joaquin Pim C <br /> D17AW <br /> PLOT PLAN ON RE ERSE SIDE) ien o an oaqutn uiphur Ce' I` <br /> FOR DEPARTMENT USE ONLY v en o St. <br /> PHASE I Lodi, Calffarnia 95240 <br /> APPLICATION ACCEPTED BY DATE =�Z—22 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE,:,jIyU4qAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ej DATE <br /> 2 <br /> Rev. 1-74 <br /> E H 1426 _ 3/76 <br />