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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE': 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I / Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7/ <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,/-d <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 Joagi <br /> County Ordinance No. 1862 and:the Rules and Regulations of the San Joaquin Local Health District <br /> EAST 7/ad L/NE f/aei as' P,, F <br /> JOB ADDRESS/LOCATION /1y77Lr=1n a ✓ L ,4/ 6-19S 7-_ 5-1oe- aF F2crri 5He tJ CENSUS TRACT <br /> Owner's Name C Rh W Aj t- Oct i c) . _ - Phone ,369- Z 73Y <br /> Address L I r Kt l iGL/V IMJ City L:oi.7 / <br /> Contractor's Name San Joaquin Pump Co. License # Phone 3�`f��7� <br /> fn St <br /> Lodi, Cclifurnis 95.290 _ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN-/':/ . RECONDITION /_� DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool c,' Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/publics. i Driven _ _ — _ _ Gauge-of-Casing _ <br /> Irrigation 11 Gravel Pack Depth of Grout Seal <br /> j Other Rotary Type of Grout <br /> t Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> TypeofPump H.P. <br /> PUMP REPLACEMENT: / IqofState Work Don e,;� /n!c e D_&L_ PUN t2 ctJ P'iS�rgrmt2G�a�- <br /> 3 e ll <br /> PUMP REPAIR: / / State Work Done <br /> I ,pESTRUCTION 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. San Joaquin Pump Co. <br /> (Dirision of Son Joaquin Sulphur Co.) <br /> SIGNED ii� � TITLE 711 N Sacramentc St <br /> (DRAW PLOT PLAN ON REVERSE SIDE 1 ,A: <br /> FOR DEPARTMENT USE ONLY DATE / L6 �� <br /> t <br /> PHASE I, n <br /> APPLICATION ACCEPTED BY (f ' U' <br /> ADDITIONAL COMMENTS: PHASE III INAL INSPECTION <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7177 tta <br />