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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> l OFFICE USE: 4/ 1601 E. Hazelton. Ave. , Stockton, Calif. k <br /> f Telephone: (209) 466-6781 , 376p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -/y 7 7 <br /> (Complete In Triplicate} <br /> Application is hereby made to the San Joaquin Local Health Distract fot 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 /> JOB ADDRESS/LOCATION I ,e7`2 zx e,•,4,o CENSUS TRACT <br /> N' <br /> Owner's Name7 f Ti G Phone 399- e!Z 7 <br /> Address 7 City , G U DC7 - -- r <br /> Sats Joaquin Pump CO. � <br /> Contractor's Name 1 r,; a in Sulphur Co.) License # 3�Q 7�Phone ' I <br /> 11 N. So.ra aenta St. <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN RECONDITION RECONDITION / / DESTRUCTION / <br /> AL <br /> PUMP INSTLATION PUMP REPAIR/ / PUMP REPLACEMENT I <br /> ' Other / / � — <br /> } <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 <br /> M Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> Cathodic-.:Protection -Rotary --- Type--of Grout - <br /> Disposal Other `. C, ` Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION:INSTALLATION: Contractor <br /> Type' of Pump H.P. <br /> � PUMP REPLACEMENT: State Work Done <br /> PUMP .REPAIR:_. State. Work _Done <br /> I 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 thelbest of my knowled e and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING INAL I SPECT ION. <br /> TITLE San Joaquin Pump Co. <br /> SIGNED <br /> E <br /> j(D - PLOT' PLAN 'ON RE ERSE SIDE) D'visioa af:�ah' haquin 14hur o.y ,''i: <br /> FOR DEPARTMENT USE ONLY 1 N "` y`c <br /> Lodi, Cal"i`orlia 95 40 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> i ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE. INSPECTION BY DATE <br /> 3/7{� 2m <br /> ! `... 'TE H 1426 Rev. 1--74 <br />