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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i AFOF O FZCE U E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> J Of Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7/�7- <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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 4-717 z_ �,,gg��,T�rG <br /> I JOB ADDRESS/LOCATION riJpr�iN / F_y1Grr3�2 gdG o� W 6E & 64fPNSUS TRACT <br /> Owner`s Name ,��i /��l.e-.Q _ K,IV lJ L L - Phone Cl S' <br /> AddressjlSD 96-,/ /�i��.ei�S� G:�71 City <br /> Contractor's Name Son JOG-quan Pcarnp CO. License # 7 <br /> Phone4 �1 <br /> TYPE OF WORK (Check) : NEW WELL / / v DEEPEN/ RECONDITION /_/ DESTRUCTION /-7PUMP INSTALLATION / UMP REPAIR 1-7 PUMP REPLACEMENT <br /> r Other { / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY T 4� <br /> SEWAGE DISPOSAL FIELD , CESSPOOL/SEEPAGE PIT OTHER v <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL _ _ { -CONSTRUCTION SPECIFICATIONS <br /> L 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 /> E Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information \ <br /> Geophysical _ Surface Seal Installed By: -_ <br /> E PUMP INSTALLATION: Contractor At JI <br /> Type of Pumpfc .P trcJ�' w H.P. `Z S7' <br /> PUMP REPLACEMENT: / / State Work Done <br /> �. PUMR.,..RERAIRs, -- - /r../. :State Work=Done�. .. <br /> 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 thewell in use... The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING FIN L NSPECTION <br /> SIGNED TITLE Son Joaquin Pump Co. <br /> } (D d PLOT PLAN ON REVERSE SIDE) .tt` <br /> FOR DEPARTMENT USE ONLY Lodi, California 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIOhr PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M <br /> E H 1426 Rev. - 1-74 , <br /> a - <br />