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05 SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2Z- <br /> THIS <br /> Z-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 18,12 and the Rules and Regulations of the San Joaquin Local Health District. <br /> Z2 fa -._. + ST e- Sde�riV 0,FPFLTiE.� QD puss f S r oc <br /> JOB ADDRESS/LOCATION 0,r r 2e CENSUS TRACT32— <br /> Owner's Name C , LA-J , p", %/-/ Phone <br /> Address _ -�� to'. Z-0e tes ! City - -.Q,0 _ <br /> 5on Joaquin ��-?/a,PUMP Ca. - -- <br /> Contractor's Name an cmJaa y9n SuIphar CO-) License �?Phone .._ f-7/' <br /> 711 PJ. Sacramento St. <br /> Lodi, Lc ifornia _ _ i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/_/ RECONDITION / DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / UMP REPLACEMENT /-7 <br /> Other / / \N <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 <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. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /—--State Work Dane 4d4 !(!!!?d �O /�C zZ/p <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply. with all lams 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU FINAL INSPECT N. �71i SOCp <br /> SIGNED TITLE A p Co. <br /> W PLOT PLAN 'ON RE FRSE SIDE) ;;"' ° v °fi ° ' <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY Lodi, C;aiifarnio 95 40 <br /> J <br /> APPLICATION ACCEPTED BY DATE 3/q 77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE I/FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE , <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />