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_ 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 <br /> THIS PERMIT 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 Na. 862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> /04exGe 6--1 c.v BST S' r o e O F Tfr6�.vTi+-✓ <br /> JOB ADDRESS/LOCATION 20o0 Sowrt-1 CENSUS TRACT <br /> Owner's Name e / ' Phone (n8 "' 1 C <br /> Address a N -to"e-070--d 2-D City <br /> Ipp <br /> Contractor's Name (Division of Son Joaquin Sulphur Co.) License 11 .310378 Phone 36— V7 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION /_/ DESTRUCTION /7 <br /> AL _ <br /> PUMP INSTALLATION / / _PUMP REPAIR /—/—PUMP PUMP REPLACEMENT <br /> Other <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 6\ <br /> Domestic/private Drilled Dia, of Well 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. n <br /> PUMP REPLACEMENT: /tate Work Done z2Z SCJ�[•T i�([y1 ,� <br /> PUMP .REPAIR: / / State Work Done - - <br /> DES,TRUCTI.ON OF WELL: Well Diameter Approximate Depth <br /> ---•may------- <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 %MLj", &,Ir }�T . NSPECTION <br /> PRIOR TO GRO AND A FINAJ, I 5 U . (Division of San Joaquin $u!p.iur Goj <br /> SIGNED TITLE <br /> RAW LOT PLAN ON REVERSE SIDE) Lodi, _ > <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION u I PHASE III/FINAL INSPECTION �} <br /> INSPECTION BY DATE INSPECTION BY / DATE 3 <br /> E H 1426 Rev. - l-74 <br /> p�77 _ 2M <br />