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SAN JOAQUIN 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. p , <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/O s <br /> (Complete In Triplicate) <br /> Application is hereby made to the Son 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 /> JOB ADDRESS/LOCATION /Icy_ SowjS,a� �1a�t,rt /Z� A&US CENSUS TRACT <br /> Owner's Name — Phone 3 - <br /> Address City M ad Q <br /> Contractor's Name San Joaquin Pump Co. License # Phone 3jc14 q7� <br /> Lodi, California 95240 -.--_ <br /> TYPE OF WORK (Check) : NEW WELLII DEEPEN /? RECONDITION � DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR -J: PUMP REPLACEMENT /7 <br /> AL <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 <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: , / / State Work Done <br /> PUMP .REPAIR: Ki _ state Work Done a 4- lepf a cL_ u -- <br /> IIE&TRUCTION 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. INSPECT N. <br /> SIGNED TITLE Son 1=11in <br /> (DRAW PLOT PLAN ON REVERSE SIDE Dirision A�FR_ <br /> FOR DEPARTMENT USE ONLY P I N. Sacramento St, <br /> PHASE I ,06* Lodi, Colifornia 95240 <br /> APPLICATION ACCEPTED BY C. DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II OUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 h/75r 2M J <br />