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G <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> !OF-";OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit jo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> {Complete In Triplicate) OCg- p5,0__kU <br /> Appliceirian is hereby Sada to the Sari Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in coit►pfia� ce with San Joaquin <br /> County 'Ordinance No: 1862 and' the Rules and Regulations o£ the Ban -Joaquin Local ..He,alth District. <br /> 'ry rXe arN Sial OF d�Qs.2TY ��d - r�,.Ars C A&T, <br /> JOB ADDRESS/LOCATION of ac -- " 'CENSUIs TRACT <br /> Owner 1d1�Name _�. .5'i_r/,lt . ..,..�..---- ,_. Phone <br /> r <br /> Address citq, <br /> Contractor's Name Sort ;looquin Pum Co. License . J(Phone 37/ <br /> .131on at.San joaquin Sulphur c9i <br /> N TYPE OF WORK (Check): &% nV71%EEPEN '/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION _ <br /> -L-] pump REPAIR- -7 P[TI� REPLACRoff <br /> other L7 <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 �1 <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 #I: <br /> PUMP INSTAELLATION: Contractor <br /> Type of Pump B.P. ' <br /> PUMP REPLACEMENT: /a f "State Work Done Xe L a �,egiar_ „al,22K.L/ <br /> PUMP �REPAIR: / 7 State Work Done <br /> DLS•TRUCTION 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 cdiMP <br /> letion 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-beet-of. my.-knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO"GROUTING AND A FINAL INSPECT N. <br /> SIGNED TITLE San Joaquin Pump Co. <br /> DRAW PLOT PLAN ON REVERSE SIDEMAIM a! <br /> FOR DEPARTMENT US <br /> PHASE I E ONLY Lodi, California 95240 <br /> APPLICATION ACCEPTED BY DATE- 7 <br /> ADDITIONAL COMMENTS: <br /> PHASIC 11 GROUT INSPECTION PHASE III FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE l o <br /> E S 1426 Rev. 1-74 l h/75 2M <br />