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_ SAN JOAQUIN LOCAL HEALTH DISTRICT .. <br /> FOP: 4F ICE USE: � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ,466-6781 �� 37� <br /> APPLICATION FOR WELL CONSTRUCTION STRUION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 &-71 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Drd'pance No. .l an �e Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1 J CENSUS TRACT ' <br /> 4 Owner's Name esd 00Phone a6l <br /> 4 <br /> Address ll �` ..�y �/ City . <br /> i � / <br /> Contractor's Name ��O�iauit9 Pump Co. License ;r��`�� Phone �teZ <br /> TYPE OF WORK (Cheek) : NEW WELL ,/ / DEEPEN / / RECONDITION I I DESTRUCTION /7' 4 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST:" SEPTIC TANK SEWER LINES.,, PIT PRIVY i7 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER �} <br /> PROPERTY'LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 5 <br /> 41 INTENDED USE =? N, TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> . Industrl-al- X -= 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 <br /> Disposal Other Other Information - _ <br /> Geophysical ° Surface Seal Installed By: <br /> k <br /> PUMP INSTALLATION: Contractor <br /> TYPelof Pump H.P. <br /> PUMP REPLACEMENT: �, S� <br /> te Work Done lace 1w<141 - <br /> F PUMP .REPAIR: / / State Work Done <br /> IDES-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 Californiapertaining to or regulating well''construction. Within FIFTEEN DAYS <br /> after completion of my work: on a new well,_Iwwill furnish_the San Joaquin Local Health District <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 /> PRIOR TO ING AND F N. _ <br /> �..,-• ---TITLE��$cn'.'Joc�'gisin-Pump CO. <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SID irssoon o an uaquin u p ur a. <br /> FOR DEPARTMENT USE ONLY Lodi, California 95240 <br /> PHASE I �. <br /> APPLICATION ACCEPTED BY DATE 4'- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �'� '�� <br /> 2M <br /> ti E H 1426 Rev. , 1-74 - <br />