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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ;;OFFICE US13: v 1,601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE'ISSURD Date Issued ,Z-7 <br /> (Complete In Triplicate) OG?_ 050_,CU . <br /> Applicaliion is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/orinstall the work herein described. This application is made'in coinpiiance with San Joaquin <br /> County'„„Ordinance No: 1862 and' the Rules' and Regulations of the-San •Joaquin LoaRl,Health District. <br /> .GTy r a�.Tf/ Sim dF t”VCAZTY 'ea44 --Z /W-14CS EAS T, <br /> JOB ADDRESS/LOCATION F r av -- " Ck3NSa8 TIkACT <br /> Owner'i j Name Phone <br /> Address� JCity ,S/i-U <br /> Contractor's Name San Joaquin Pum Co. LicenseID37 3r1 <br /> • r sion o an oaqu n u p ar Co.) E�Phone <br /> gy�pp"� . <br /> TYPE OF WORK (Check): �Ep WEL° " "SEEPEN "/? RECONDITION &' DESTRUCTION 17 <br /> PUMP INSTALLATION ' _? PUMP REPAIR-/? PUMP REPLACELMNT f <br /> Other /7 <br /> . . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRaA DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF.WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well. Excavation ~ <br /> Dquestic/private Drilled Dia. of Well Casing N <br /> Domestic/public Driven Gauge of Casing . m . <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary - Type of Grout <br /> i Disposal Other Other Information' <br /> Geophysical Surface Seal Installed ft: <br /> f, <br /> PUMP INSTALLATION: Contractor <br /> i Type of Pump N.P. . <br /> PUMP REPLACEMENT: . /!tel State Work Done --. <br /> Pon t REPAIR: ET State Work Done <br /> BES.TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 coiapletion 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 put ting.the..well, in.use.... The above <br /> information is true to the.beat"of. my".knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIUR 1►0'GROUTING AND A FINAL INSPECT N. <br /> SIGNED �- TITLE San Joaquin Pump Co. <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> � <br /> ca- <br /> PHASE I FOR DEPARTi±MT USE ONLY Lodi, California 95240 <br /> APPLICATION' ACCEPTED BY <br /> ADDITIONAL COI�MMENTO: DATE 7 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPk3CTI <br /> INSPECTION BY DATE II+TSPBCTION BY DATE /o <br /> V <br /> E H 1426 Rev. 1-74 � h/75 2M <br />