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SAN JOA UIN LOCAL HEALTH DISTRICT <br /> [O OFFICE USE: Y jL' 1601 E. Hazelton Ave. , Stockton. Calif. <br /> V Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. `3 OC I <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 District for a permit to construct <br /> i 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 5 , S, is ewe!/ Sje— CENSUS TRACT <br />{I Owner's Name L t-V0 G. ^ C[r l�a S CaR,-A.tk-N�i _,. ._... .._ Phone 3l� -30 <br /> Address City G o 4 1 <br /> Contractor's Name License # 2 '- Phone36Y c{'Y71 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION /1/,? PUMP REPAIR / f PUMP REPLACEMENT / f <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 PUBLTC 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 �,>A -eC,tJ pan-to Gd_ <br /> Type of Pump .5�"a A4E;fLSI eSL H.P. <br /> F <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR-. / / State Work Done C <br /> x 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 puttingthe well in use.... The above <br /> k information is true to the best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> t 'RIOR TO GROUTING AND A F NSPECTION. <br /> SIGNED TITLE Scan Joaquin Pump Co. <br /> (DRAW BMT PLAN ON REVERSE SIDEr 'n'ra 'l `0'ur CUF <br /> FOR DEPARTMENT USE ONLY <br /> l PHASE I Lodi, Culiforwa 95240 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE III/FINAL INSPECTION <br />€€ INSPECTION BY DATE INSPECTION BY �, —^ DATE 9 zZI!7 <br /> f � <br /> R <br /> E H 1426 Rev. , 1-74 b1��7 _ 2M <br />