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Ar <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EO_F, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zti_114 a�' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> Count tt Ordin nce No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> , �® ..r�, �11ro 69-Sr O•J J'�H.W.v7^' /01a7-1V 041 &.eA/If m '/2 m,1e� <br /> JOB ADDRESS/LOCATION OA.) sf Si e, ogVjn CENSUS TRACT - <br /> .,Owner's Name [,r.jL `+�! Phone 6 ' Z 3 2_0 <br /> Address A 41 10. City IaCAk-i-k Po <br /> Contiactor's NameWON Of <br /> San Joaquin Pump Co., License # 03 Phone <br /> 711 <br /> i <br /> Lodi, Cajifarnia 95240 <br /> TYPE OF ;WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT /_7 <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing IN) <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 /> w-FGeophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of,Pump S u H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done _ <br /> DES-TRUCTION OF WELL: Well Diameter 'r Approximate Depth <br /> Describe Material and Procedure <br /> 4 <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 /> PRIOR TO GROUTIFt,,MD A FINAL INSPECTIOW Son Joaquin ,Pump Co. <br /> SIGNED TITLE <br /> -_ (Masmoa of <br /> RAW PLOT PLAN 'ON RE FRSE SIDE) <br /> FOR DEPARTMENT USE ONLY Lodi, Caiifarnia 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE'/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 3/7b 2M <br />