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9 SAN JOAQUIN LOCAL HFALTH DTSTRICT <br /> FOR. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Califf, <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> PPlication is hereby made to the San (Joaquin pTriplicate) <br /> LocallPalthtDistrict for a permit to construct <br /> nd/or install the work herein, described. This application is made in compliance with San Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 3B ADDRESS/LOCATION <br /> '� �i't G i S - CENSUS TRACT <br /> Owner's Namehr- < 5 C td <br /> -- Phone <br /> Address / k- / 5 / ._ -4 A? --- <br /> -- - - City C,c)t-)i <br /> )retractor's Name San Jeccuin Pump Co <br /> License 3/U 3 7 � Phone <br /> r n o an �aGu;n .•ui�h�.. - <br /> CoJ <br /> .'PE OF WORK (Check) : NEW WELL / y` DEEPEN / % P.ECONDITION /-] DESTRUCTION /_7 <br /> PUtff' INSTALLATION / / —PUMP — -7 <br /> REPAIR /Z:/ PUMP REPLACEMENT <br /> Other /% -- <br /> STANCE 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 e <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 <br /> Type of Grout <br /> Disposal Other . Other Information <br /> Geophysical __— Surface Seal Installed By: <br /> 'UMP INSTALLATION: Contractor <br /> Type of Pump �- H.P. <br /> 'UMP REPLACEMENT: / ./ State Work Done <br /> ' 1P .REPAIR: <br /> - /77-- State Work Done � � /� -,t? 1,1 �! its t7 <br /> IP'TRUCTION OF WELL: Well Diameter <br /> - - Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> u the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> .i?-ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 'ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> i ormation is true to the best of my knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> R )R TO GROUTING AND A FINAL INSPECTION, <br /> IGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) . <br /> FOR DEPARTMENTUSE ONLY " <br /> RASE I <br /> PnLICATION ACCEPTED BY CJ Lodi, `�F r <br /> CITIONAL COMMENTS: <br /> DATE <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br />