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, SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS,OFFICE USE:r� ✓ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75-=5741 . <br /> I <br /> THIS PERMIT EXPIRES I YEAR FROM DATE-ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Son 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 /> - i <br /> JOB ADDRESS/LOCATION .Sau+�� ,�e I i, 4., al VuelkewatCENSUS TRACT <br /> ,Owner's Name .6reue Phone 3 69- 12-49, { <br />.!.Address iS 4 I l 7 S' tZ City , /-001 - <br /> Contractor's Name San Joaquin Pump CO. <br /> License # Phone ; <br /> Lodi California '" 40 - <br /> TYPE OF WORK (Check): NEST WELL /-7 DEEPEN /7 RECONDITION /-7 DESTRUCTION 1-7 I <br /> PUMP INSTALLATION / / PUMP REPAIR -/-7—pump REPLACEwd— <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER G`l <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL:_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS O <br /> 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 /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Worst bone <br /> .. f <br /> PUMP .REPAIR: State 9Work Done <br /> F, 1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 1 <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 anew 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 <br /> PRIOR TO GROUTING AND A FINAL I SPECT N. Son Joaquin Pump Co. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY Lodi, California 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROT INSPECTION, . <br /> NSPECTION PHASE III FINAL INSPECTI N <br />, INSPECTION BY DATE INSPECTION BY DATE / <br /> R R 1l,2F, ao<, -7 If. i 1.17c 9M <br />