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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEOFFICE USE: 1601 E. Hazelton'-Ave. ; Stockton, Calif. <br /> ' Telephone: (209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S_— � <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 $ 2 d the Rules and Regulations of the San Joaquin Local Health District, <br /> LO <br /> Y� 1 64r _ coF 7Zf0-wCe ROAp , EasT of <br /> JOB ADDRESS/LOCATION pi ^, L CENSUS TRACT <br /> Owner's Name por Phone 267=' 2�cl <br /> Address City 4, 001 <br /> Contractor's Named <br /> qPzd` Cd/ License �� Phone <br /> T <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/% RECONDITION /� DESTRUCTION /^7J <br /> PUMP INSTLATION REPAIR / PUMP <br /> ALREPLACEMENT /_7 <br /> Other <br /> f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE I 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 _44 Other Information <br /> Geophysical }Surface Seal Installed By: <br /> UMP INSTALLATION: Contractor <br /> Type Of Pump H.P. . <br /> 1 <br /> PUMP REPLACEMENT: / / State Work Dane <br /> PUMP .REPAIR: _ _State Work Done c C� 7u z k 5 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe 'Material and Procedure <br />` a <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 <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT A FINAL} ISPE <br /> SIGNED { s TITLESAN JOAQUIN PUMP-COMPANY ' <br /> (D PLOT PLAN ON REVERSE SIDE) B60 E,Pine -qtrppt <br /> FOR DEPARTMENT USE ONLY P. 0. Box 201 <br /> PHASE I Lodi, Ca � <br /> APPLICATION ACCEPTED BY Wjg4 95240 i <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - ? ' <br /> E H 1426 RPV_ . 1_7L 0!77 _ QM <br />