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f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t FOVOFFICE USE: v 1601 E. Hazelton Ave. , Stockton Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ' -1,710 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <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 /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name / /?;,r,+ AJ (,j �flS� Phone <br /> Address 7 q 7 W , (VCL A_jLt 1 —2 .�a►9 City <br /> San Joaquin Pump Co. <br /> 1 Contractor's Name of oa uin Sui hur Co.) License # Phone 367^-N -7 f <br /> 1 N. Sacramento St. <br /> T f - __od't; CoEifornia`�I:1 _ <br /> TYPE OF WORK (Check)•: NEW WELL /7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUME REPAIR PUMP REPLACEMENT /- <br /> ,Other / / — <br /> i —� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> t � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial . Cable Tool_ _N_._. Dia-. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing �t <br /> Domestic/public Driven Gauge ofCasing <br /> k Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other 'Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: = mI�StateYWork;Done 7 <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 District1 <br />, and the State -of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> y <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> DWELL 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. <br /> SIGNED �/ Son Joaquin Pump Co. <br /> �� �` L ��� TITLE (Division of San Joaquin Sulphur Co.) <br /> i <br /> (DRAW PLOT PLAN ON REVERSE S1 711 N. Sacramento -St.- <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY Lodi, kxll arnta 93440 <br /> i <br /> APPLICATION ACCEPTED BY DATE / /S` �' i <br /> kADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br />' INSPECTION BY DATE INSPECTION BY DATE a „ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. I <br /> E H 1426 7/72 lM <br />