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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 No•.> <br /> THIS PERMIT EXPIRES 1 YEAR FROM k M DATE ISSUED Date Issued 7,�7 <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 Joaquih <br /> County Ordinance Na. 1$62 and the Rules and,,Re IatIons of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> I Owner's Name 4 <br /> { Phone <br /> Address � -7 4 /ZJ. .QG �iG S +� City -6001 <br /> f Contractor's Name Son Joaquin Pump Co. <br /> License # 3ffi37kPhone3611V7j <br /> Lodi, Ca;ifoniea 95240 <br /> -TYPE OF WORK,(Check)-: -NEW�.WELL ./ -/_ DEEPEN / �/ :-RECONDITION_/ /_,_DESTRU,CTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /cPUMP <br /> Other REPLACEMENT <br /> / / t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITJ <br /> SEWAGE DISPOSAL FIELDCESSFOOL/SEEPAGE PIT OTHER j <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WEL <br /> INTENDED USE _ TYPE OF WELL COL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> ° ► Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled <br /> Dia. of Well Casing �•� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation l Gravel Pack Depth of Grout Seal d <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other" Other information <br /> Geophysical Surface Seal Installed By: <br /> *' ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT. , e `t <br /> / / State Work Done - <br /> PUMP .REPAIR: I ! <br /> /L�State Work Done R £ /S A 0 <br /> DESTRUCTION OFWELL: Well Diameter <br /> Approximate Depths - <br /> Describe Material and Procedure _ {{ <br /> � I <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 i <br /> information is true to the best of myknowledge and belief. I WILL CALL FOR. A GROUT INSPECTION I <br /> PRIOR TO GROUTING FINAL I SPE <br /> SIGNED TITLE San Joaquin Pump Co. <br /> D Pi T PLAN 'ON REVERSE SIY3E ' <br /> �. ,. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Lodi, Cauarsio 95--,40 ., <br /> APPLICATION ACCEPTED BY ' s.Y.. y 1 <br /> ADDITIONAL COMMENTS: # DATE - 7 "' <br /> PHASE II GROUT INSPECTION <br /> PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> i4. <br /> f <br /> E.H'14.26 Rev. 1-74 3/76 2M <br /> - ,. <br />