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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 1� <br /> Telephone: (209) 466-6781 A/ �6 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT �erm3t No. <br /> p THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /2-/3 7J <br /> ` 7Qo £- mAd-DEc. 4_4. (Complete In Triplicate) O( 3_ ��7j -�yC <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 �ej S de o� h�7C.tJlf' G,(���,q ,p_,l�f•� CENSUS TRACT <br /> Owner's Name 6j72-I.-L) / Phone , 6F_ <br /> ! 2rjZ7 <br /> Address < 2C_ ��A/�..Gl�� Gam/ City GOOD <br /> oaquin PUMP Co. <br /> Contractor's Name to1Y1S1O^°"on 1°^p°in Sulphur Ca} License # �� Phone 76f�5�7/ <br /> n. Sacramento St. <br /> mo <br /> TYPE OF WORK (Check) : NEW WELL /% DEEPEN /% RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / MP REPLACEMENT /_7 <br /> Other <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 /> .J' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: _ State Work Done �, /� lQ/5�j� z7,a Awer ld <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 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 be ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTINGNAL 4N ECT Son Joo <br /> SIGNED TITLE quin Pump Co. - <br /> LOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY Lodi, California 95240 <br /> APPLICATION ACCEPTED BY �_ t jn �o _ DATE -2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION - PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3-30 7p <br /> E H 1426 Rev- 1-74 . 6/77 _ 2M <br />