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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORIOFF�CE USE: � x6O1E'. Hazelton Ave. , Stockton, Calif. ;„ g <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. . <br /> r JJ <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued 1 6 9978 <br /> (Complete In Triplicate) n 3� .25o -oma, <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 Ordinance the -Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION rvB CENSUS TRACT <br /> Owner's Name , • Phone 92,3,- RSA/y- <br /> Address /'S7 3 3 Ii:�i�'a�T ul�f City /�JiQ.iJT�a� i <br /> Contractor's Name sari 1004uin PuPvto Co, License. # 310378 Phone <br /> r <br />.TYPE OF WORK (Check):: _NEW WELL / /� DEEPEN /_// RECONDITION / / `DESTRUCTION /�" _ <br /> PUMP INSTALLATION % / PUMPREPAIR / / PUMP REPLACEMENT- <br /> Other <br /> r, <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 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool. Dia. of Well �,Excavation <br /> Domestic - <br /> /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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H,p. ` <br /> PUMP REPLACEMENT: /Mate Work Done <br /> PUNP .REPAIR: / / State Work Done <br /> bES•TRUGTrON�Ok'-WELL: Well Diameter x T � 4 4: <br /> 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 there before putting the well in use. The above <br />.information is true to the best ofmy knowle and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU D A FINAL INSP <br /> SIGNED TITLE San Joaquin Pump Co. <br /> W PLOT PLAN ON REVERSE STD on Joaquin Sulphur CQ <br /> ' FOR DEPARTMENT USE ONLY " <br /> PHASE I Lodi, Califarnia 95240 j <br /> APPLICATION ACCEPTED BYDATE R 3 <br /> ADDITIONAL COMMENTS: I A01 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7-/�-7dp <br /> �­_E H 1426 Rev. , 1-74 - h - xr x./77 - 2M <br />