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r / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. Stockton Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �_76 <br /> (Complete In Triplicate) j <br /> Application°is hereby made to thelSan 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 /> • S <br /> JOB ADDRESS/LOCATION �5�Pe lee p-eie-S-e-. CENSUS TRACT <br /> Owner's Name .' '. r Pho ec• 2'3� <br /> Z Y-- <br /> Address 7 Y 17 fU , (L)Q[ >Uu.T r2aflE R City <br /> - -- <br /> Contractor's Name San Joaquin Pump Co. License # Phone <br /> 1 iv+sion or S971 jouqum ulp o. J - <br /> TYPEOF WORK- (Check):: �1 J LS� ' EEPEN /� RECONDITION% _DESTRUCTION <br /> PUMP INSTAL_%LATION / / PUMP REPAIR � PUMP REPLACEMENT /7 <br /> _ Other <br /> _ I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ! <br /> { <br /> SEWAGE DISPOSAL FIELD '' CESSPOOL/SEEPAGE PIT OTHER 1 <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 j <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 -bo e I <br /> PUMP REPAIR: /+ State Work Done jegj7 ,5 a'c`�RA/z" <br />,RESTRUCTION 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. <br /> San Joaquin Pump Co. <br /> `r <br /> SIGNED TITLE (Division of San Joaquin Sulphur Co.) <br /> l` - � <br /> (DRAW PLOT PLAN ON REVERSE SIDE Sacramento-St. I <br /> FOR DEPARTMENT USE ONLY Lodi, "Ilrarnia 5iaZlfUt <br /> PHASE I i <br /> APPLICATION ACCEPTED BY - _- -_-- - _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> f CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />