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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB OFFICE USE: 11601 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 2-2Z-2 <br /> (Complete In Triplicate), <br /> Application is hereby made to the San Joaquin Local Health Districtfor a permit to construct <br /> and/or install the work herein described. This application is made incompliance with San Joaquin <br /> County Ordinance. <br /> So. 186 and t ' Rul'� Re u1$tio�}Q/° t San Joaquin Local Health District. <br /> � . . <br /> JOB ADDRESS/LOCATION S /� CENSUS TRACT 132-070-10 <br /> Owner's Name C 6IJ Phone 462 -- 3s 7 <br /> Address City ;S 7-d Ck 70 <br /> Contractor's Name Son Joaquin Pump Co. License Uiib"-37$' Phone 3f <br /> (VIVIVOK OF gut]j-U'4uh' 9-IFI-12 . <br /> mmmnt <br /> ­24 <br /> TYPE OF WORK (Check): NEW W Iffl % gDEEPEN /_7 RECONDITION + DESTRUCTION /-7- �� $ <br /> PUMP INSTALLATI6NI /-7 PUMP REPAIR A?-PUMP REPLACEMENT % W <br /> Other / / <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY W <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 E <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 /> 1 <br /> Type of Pump A.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> r' r <br /> PUMP 'REPAIR; /State Work Done <br /> V <br /> DES-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 puttingthe .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 T'0 GROUTING AND A FINAL INSPECTION <br /> SIGNED TITLE Son Joaquin Pump Co. <br /> DRAW PLOT PLAN ON REVERSE SIDE (Division of San Joaquin Sulphur Co.) <br /> FOR DEPARTMENT USE ONLY ac a. <br /> PHASE I Lodi, California 95 40 <br /> APPLICATION ACCEPTED BYDATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT NSPECTION PHASEAIJ FINa INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE / <br /> E H 1426 Rau_ <br />