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y <br /> VV SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR'OFFICE USE: 1601 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 3_2g <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 Ruffles and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION $LeG1C 674S7_ o_1C 5�I57 CENSUS TRACT <br /> Owner's Name CAS 7 StO66.. G�J`iv , <br /> � Phone 701 g7 V&ef � <br /> Address (2 Ie D 6 _ _V Y_-49- City <br /> Son Joaquin Pump Co. � <br /> Contractor's Name <br /> c ; .. License # Phone <br /> Lodi, California 9521.0 f <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP 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 WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/publfc 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 i <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR,. State-Work. Done <br />,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure f <br /> k <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 /> San Joaquin Pump Co. <br /> SIGNED TITLE (Division of San Joaquin Sulphur Co.) <br /> (DRAW PLOT PLAN ON REVERSE SIDE) Al5aeramer� o 5t. <br /> FOR DEPARTMENT USE ONLY Lodi, K-GRIM-010 Y3,250 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE L d J <br /> ADDITIONAL COMMENTS: a <br /> PHASE II GROUT INSPECTION PHASE III FINALINSPECTION <br /> INSPECTION BY DATE INSPECTION BY �µ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M "' <br />