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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , .Stockton, Calif. 4 <br /> 1 Telephone: (209) 466--6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 /> JOB ADDRESS/LOCATION t CENSUS TRACT '%- S '�I <br /> Phone " 369-2845 <br /> Owner's Name a erg Electric' CO**--- <br />—Address 6 9 H r City Lodi, <br /> - Com Iiie.. License # 271800 Phone 369-8471 <br /> Contractor's Name San Joacuin � �� <br /> TYPE OF WORK (Check) : NEW WELL JM/ DEEPEN -/ / RECONDITION /� DESTRUCTION /,T `x <br /> PUMP INSTALLATION / / PUMP REPAIR I I PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �. <br /> J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial XX Cable-T,00l Dia. of Well Excavation 8 <br /> Domestic/private Drilled . —, .Di-a. of Well Casing 8 m <br /> Driven ` Gauge of Casing 12" <br /> .Domestic-/public- � .�.-- ,- ': • <br /> - rt -'On �. Y --- .Gravel�Eack _,.....�.De th-of...Grout;Sealer �._. . . . <br /> Ixrigata. �t.—' . Type of Grout <br /> Other Rotary yp <br /> Other Other Information <br /> N <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> 1 ,pESTRUCTION 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. <br /> The above <br /> information is true to the best my kno edge and be ef. <br /> SIGNED ' ITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT US <br /> PHASE I - DATE / `c�L" •Z-- <br /> APPLICATION ACCEPTED BY <br /> j ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE <br /> INSPECTION BY DATE INSPECTION BY , <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 1M <br /> E H 1426 <br />