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SAN JOAQUIN LOCAL'HEALTH '61STRICT <br /> t WOFFICE USE:- 1601 E. Hazelton'Ave:;,St6ckt'ori, Calif. <br /> Telephohe:-,(209) 466--67.81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ 2_Llo <br /> .r <br /> THIS PERMIT EXPIRES 1 YEAR• FROM DATE ISSUED Date Issued /-2=7-1- <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 CENSUS TRACT <br /> Owner's Namew Phone 3il7 r -O 3 <br /> Address f? <br /> City <br /> 9 <br /> Contracto is Name r ? P��y/1 License # Phone ,.;'jj*; Y71 <br /> TYPE OF WORK' (Check) : NEW-WELL /?, DEEPEN. , RECONDITION /-7 DESTRUCTION /_7 ! <br /> PUMP INSTALLATIONl/ i PUMP REPAIR PUMP REPLACEMENT %j <br /> Other R"' e <br /> DISTANCE TO NEAREST: SEPTIC TANK,%. 1 1.V SEWER"EINES t I PIT PRIVY. <br /> SEWAGE fDISPOSALJFfhDI14- , CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE-—PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ` <br /> . INTENDED USE:. TYPE OF. WELLr, CONSTRUCTION SPECIFICATIONS <br /> industrial Cable ,Tool Dia. of Well Excavation <br /> Domestic/private ; Drilled- - ""'- '"' Dia. of Well-Caging""" -�- <br /> Domestic/public i ;Driven Gauge .of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 ""R6tary ^�'"'"""`"Type of Grout"" - <br /> I` Disposal � . - Other Other Information <br /> l sica <br /> _ Geo h ` <br />{ P Y iF" ;� Surface Seal Installed B ` <br /> i' PUMP INSTALLATION: Contractor � �fM %en ,gyp <br /> Type of Pump ,�, * 0 (Division of San Joa ui I .P. <br /> _ ! ' E. Kettleman <br /> PUMP REPLACEMENT: / / State Work Done Lodi, California,952an <br /> j <br /> -F-7—state-Work-D.... <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> i Describe Material and Procedure t <br /> I hereby agree to com1 ith�laws and regulations{ of the San Joaquin Local Health District - <br /> and the S a if ornia.pertaining-to--toulating well construction. Within FIFTEEN DAYS <br /> afte ompletion of my work on a new well, I will furn s uin Local Health District a <br /> WEL DRILLERS REPORT of the well and notify them before putting the..well n. (rg�haue <br /> information is true t�Itthh.e�bbest of-I.knowled e and belief I WILL CALL FOR A GROUT INSPECTION <br /> PRYOR TQ GRO G IN EON.SIGNEDT TITLE �' - <br /> �1 <br /> I (DRAW PLOT .PLAN ON REVERSE SIDES <br /> y ,= FOR DEPARTMENT USE ONLY <br /> PHASE I x _ <br /> APPLICATION' ACCEPTED BY <br /> DATE Ia ,27'7L '. <br /> ADDITIONAL COMMENTS: r <br /> PHASE TI GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE /,2:27Z-Z <br /> ft E H 1426 Rev. 1-74 1-74 2M `� <br />