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I/ JOAQUIN LOCAL HEALTH DISTRICT.: <br /> FOF� OFFICE USE: 66 160L.L Hazelton Ave. , Stockton, Calmer. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 6-/e1_1L <br /> THIS ,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DateIssued �76 <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' �corfpl ante with Joaquin <br /> County Otdinance� No. 1862 .and the Rules and Regulations of the San ,Joaquin,Local Health.:.Distriet. <br /> .TOB ADDRESS/LOCATION 66 .:jj CENSUS TRACT . <br /> Owner's Name Phone <br /> Address --�� -)-kJ City J�Q <br /> Sari Joaquin PumpCo. <br /> contractor' <br /> s- Name License # 4, Phone6�_9 7 <br /> Lodi, California 95240 <br /> TYPE OF WORK (Check): NEW WELL '/-7 DEEPEN '/_7 RECONDITION /7 DESTRUCTION r-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /cP7 <br /> UNP REPLACEMENT % <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 V <br /> INTENDED USE TYPE OF WELL , :CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Wel.l' Excavation <br /> Domestic/private Drilled Dia. of Well- Casing <br /> Domestic/public Driven . Gauge of -Casing <br /> Irrigation Gravel Fack Depth of Gtout--Seal -- -- - -�_ - <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal _" Other Other Information <br /> Geophysical Surface Seal Installed T: <br /> PUMP INSTALLATION:. Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / "/ State Work Mone <br /> PUMP .REPAIR: S tate Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agr-ee 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 Sari Joaquin Local. Health District a <br />` WELL DRILLERS REPORT of- the well and notify them before putting.. the..wel1: in.use... The, above <br /> information is true to the-best.of" my knowledge and belief-. I WILL CALL FOR A -GROUT INSPECTION <br /> ?RIOR TO GROU NG AND A FINAL INSPECT N. -Son Joaquin Pump Co. <br />( SIGNED TITLE fbioo_ OF 501,lefflitlin sulphur em) <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> St <br /> FOR DEPARTMENT. USE .ONLY Lodi,'Ccliforn.io 95240 <br /> PHASE I j <br /> APPLICATION ACCEPTED BY �' DATE /d LZ 71 <br /> ADDITIONAL COMMENTS <br /> PHASE -II GROUT INSPE ON PHAS IFI AL INSPECTIO <br />; INSPECTION BY DATE INSPECTION B DATE <br />