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el 'F"T JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 160 „ Hazelton Ave. , Stockton, Calmz . <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued j�y-;S <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local ltealth District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION $i+u CENSUS TRACT <br /> Owner's Name e Pe Phone 12-4k <br /> Address IS 36 % ti, iRe rily-0G- City Z_e) 0 � <br /> Contractor's Name Son Joaquin Pump CO. License # Phone e SV 71 <br /> ry sion <br /> Lcdi Cali�Grmo cs2`a.t� <br /> TYPE OF WORK (Check) : NEIR WELL / / DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <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 /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL lv <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 Type of Grout n <br /> Disposal Other Other Information <br /> Geophysical _ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done j jS %telLL Gatale /?iy,P _ <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 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 best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 'RIOR TO GROUTING AND A FINAL I SPECT N. San Joaquin Pump Co. <br /> SIGNED �- �; TITLE <br /> /i1;..:.;..., of S.-.n Innarin Sulphur CO-) <br /> (DRAW PLOT PLAN ON REVERSE SIDE) 71 Sn rag nto St <br /> FOR DEPARTMENT USE ONLY Lodi, Califorl.ia 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II LRP T INSPECTION PHASE III FINAL INSPECTI N / <br /> INSPECTION BY — f DATE INSPECTION BY DATE <br /> E H 1426 P, .> 1-7i ' ^r ",• <br />