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a 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. <br /> 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 Dietx'ict for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaq <br /> County Ordinance No. 186? and t Rule �'�d1Regul tiory��o t e. San Joaquin Local Health Distric <br /> -j2lp� �rc /"�t �3 rh/ /V �rD�f'P . •: <br /> JOB ADDRESS/LOCATION S �" CENSUS TRACT 132--0-70- <br /> Owner's <br /> 32-r07oOwner's Name' �_ .,� �-� +11e IL Phone ZI6 2 <br /> Address <br /> 3 263 l� NC12UtCES (_it1 Cit S7aGlGla <br /> y' <br /> Contractor's Name San Joaquin Pump Co. License # 7/0-37$' Phone <br /> tL),visloft <br /> hl r'no-PAraARta St <br /> Lodi Caiifocnin9D-dC -- <br /> TYPE OF WORK (Check): NEW WELL� / DEEPEN /7 RECONDITION / T DESTRUCTION /-7- <br /> PUMP INSTALLATIONi'/ / PUMP REPAIR A,�K PUMP REPLACEMENT /? <br /> Other / / <br /> i <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 c. 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 A.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: / State Work Done pu 2S!1P Z�.P&'Clr ' CA262,ek <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 a new well, I will furnish the San Joaquin Local Health District <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 GROUTING AND A FINAL INSPECTION <br /> SIGNED TITLE Son Joaquin Pump Co. <br /> DRAW PLOT PLAN ON REVERSE SIDE) (Division of San Joaquin Sulphur Ca) <br /> FOR DEPARTMENT USE ONLY ac a. n . <br /> PHASE I Lodi, Colifcrnia 952" <br /> APPLICATION ACCEPTED BY DATE -71 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT SPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE . <br />