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SAN JOAQUIN LOCAL HEALTH DISTRICT 1d <br /> FOR QFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. , <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-Valj <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued —If-77 <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 Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 1-/oGA.V LA/ -o Cu•cJeY; Sown/ as (fuga.S-, <br /> JOB ADDRESS/LOCATION ErasT ��.� s/.a. ,vT �� // CENSUS TRACT <br /> Owner's Name - Phone <br /> Address / T City Gov/ <br /> San Joaquin Pump Co. <br /> Contractor's Name (Division of San Joaquin_Sulphur Co.)_ _ _ License ����I0.3 - Phone.�?A/9-JOY7Y <br /> 711 N. Sacramento St. <br /> Lodi, aic orwo <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ // RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION /P1 PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESPIT 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 h� <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 p <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ,,� ,q <br /> Type of Pump , �miE�+Si. /Lr - - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / f 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 /> PRIOR TO GROUTING AND A SPECTIO an oaqum Pump Co. <br /> SIGNED T I TLE '(Division of San Joaquin Sulphur Co. <br /> (DRALd PL LAN ON REVERSE SIDE) Sacramivita ,Fig. <br /> FOR DEPARTMENT USE ONLY tom, "it ern'a 93ZA0 <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 / - 7-- 3 -; 7 <br /> r <br /> 0/77 2M <br /> E H 1426 Rev. - 1-74 <br /> _ <br />