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YA. - - 1/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh:OFFICE USE: 1601 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 ISSUED Date Issued <br /> (Complete In Triplicate)- <br /> lpplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ►nd/or install the work herein described. This application is made in compliance with San Joaqui <br /> ;ounty Ordiaance .No. 186 and t ' RuI d Regul tio ,o t San Joaquin Local Health District, <br /> = may,/ / �'1/�� fit/ CrO�e�P . <br /> fOB ADDRESS/LOCATION S CENSUS TRACT /32-rD?o <br /> ►wr►er's Name C. .�.J Phone <br /> ►ddress 3 2 (23N-t R0ICE C ( City .<2 To c)-- <br /> :ontractor's Name San Joaquin Pump Co. License # -7Ab-378' Phone lLs`zz/ <br /> (DIVIS1011 of Sun 1004011. sulpho 60.) <br /> . it <br /> L�dr Calif 9�24C <br /> .'YPE OF WORK (Check) : NEW WELL DEEPEN /7 RECONDITION / MDESTRUCTION <br /> PUMP INSTALLATIONi L PUMP REPAIR PUMP REPLACEMENT <br /> Other /? <br /> IISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY U <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 <br /> Domestic/private Drilled - Dia:; of Well Casing i <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protect_ion Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'By: <br /> 'UMP INSTALLATION: Contractor <br /> Type of Pump A.P. <br /> UMP REPLACEMENT: / / State Work Done <br /> _ r <br /> UMP 'REPAIR: /17-r State Work Done <br /> ES-(RUCTION OF WELL: Well Diameter Approximate Depth r^ <br /> Describe Material and Procedure <br /> hereby agree to .comply with all laws and regulations of the San Joaquin Local Health District <br /> nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> fter 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 /> nformation is true to the-best of my. knowledge and belief. I WILL CALL FOR 'A GROUT INSPECTION <br /> RIOR TO GROUTING AND A FINAL INSPECTION <br /> IGNED 2.d, TITLE San Joaquin Pume Co: <br /> DRAW PLOT PLAN ON REVERSE SIDE (Division of Son Joaquin Sulphur Ca.) <br /> FOR DEPARTMENT USE ONLY I I <br /> ' Sacromenro St. <br /> RASE I Lodi, California 95 40 <br /> PPLICATION ACCEPTED BY DATE <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT IVSPECTION. PHASE Ij FINA1, INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Raw_ 1_7A <br />