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r _ Al <br /> SAN JOAQVIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 14,6 3 pn <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -/S-7] <br /> (Complete In Triplicate) i <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 /> 4 rf <br /> JOB ADDRESS/LOCATION .��c - �sr� [j � CENSUS TRACT <br /> Owner's Name �Lza/ Phone 368-- 72.,57 y <br /> Address Z - A,2.Uf_f''- City Ga,O e5- <br /> Contractor's <br /> Contractor's Name Saes J License #,'?10376'Phone '3,624VZI <br /> (Division of Son Joaa <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION DESTRUCTION /_7 ~ <br /> PUMP INSTALLATION/ / PUMP REPAIR ~UMP REPLACEMENT /_T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 4 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL . 4 CONSTRUCTION SPECIFICATIONS \n <br /> Industrial Cable Tool- Dia, of Well Excavation VV , <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 /> PUMP INSTALLATION: Contractor ► <br /> Type of Pump H.P. <br /> i <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: /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 FINAL Iq7SPEtvnQN. _ <br /> SIGNEDTITLE Son Joaquin Purae C <br /> DRAW PtIOT P ON REVERSE S ID vision of Son ooquin sul�,e,r d0i <br /> FOR DEPARTMENT USE ONLY cramen o .t• <br /> PHASE I <br /> Lodi, California 95240 <br /> APPLICATION ACCEPTED BY DATE F-9-2 <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �, DATE //- T- 77__ { <br /> •r <br /> E H''1426 Rev_ 7-74 ' <br /> 3/76 2M <br />