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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76- 7,0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued IL-76 <br /> (Complete In Triplicate) ®2� - dD2O-l5 <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. .and the Rules and Regulations of the San. Joaquin Local Health District. <br /> t�Z70 vv- `??[ S4- CF Loc eIZ SncTa 2Q Fros4- ",e 0'v 5vzZ270 S•nE <br /> JOB ADDRESS/LOCATION or Tk vie 2c�a© , wesF o F o"u iLowd Iusmry- CENSUS TRACT <br /> Owner's Name Phone 3 6 Z 2.) '7 <br /> Address l4 12 ti+19. 40D �.DGt o^ City 0 <br /> ne <br /> Contractor's Name San Joaquin Pump Co. M1� <br /> Lie nse Ph V7/ <br /> Lodi, California 95240 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION %_j DES <br /> PUMP INSTALLATION PUMP REPAIR •/� PUMP REPLACEMENT_ <br /> Other /_7 — <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 L � e <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 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 INSPECTIO <br /> PRIOR TO GROUTING AND A FINAL INSP ION. <br /> SIGNED e TITLE San Joaquin Pump Co. <br /> {DRAW PLOT PLAN ON REVERSE SIDE Mision of Nan Joaquin u p ur o.} <br /> PHASE I FOR DEPARTMENT USE ONLY Lodi, Caflfoxnia 95240 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASUIkA= INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev.. 1-74 rr h/75 2M <br />