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s <br /> 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.7) <br /> THIS PERMIT EXPIRES 1 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 v <br /> Owner's Name L�"E ��/GGE�2. _ _ �T Phone <br /> Address <br /> _ ZDGI� /I/. �/,��,r�,r��NE �� -- city Sra�Ta.� <br /> Contractor's Name Snn Joaquin Pump Co. License Phone x;69-,FX7/ <br /> Division of San Joaquin Sulphur Co.J _ <br /> TYPE OF WORK (Check) : NEW. ALL / ' '60PEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <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 'Di'a, of Well- Excavation• p`$ <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 ZWy Df �.1817?E•pc5/�1S1� - --_-._-- H.P. 7 VZ <br /> PUMP REPLACEMENT: State Work Done )(?4A NE* 77 7A- <br /> ff PUMP' REPAIR: - /_T// - State Work Done <br /> f <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 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 GROU G FIN I SdR Joaquin PunaCO <br /> SIGNED TITLE P C <br /> RAW PL T PLAN 'ON RE ERSE SIDE °7 q4m wa ur Ca} 1•; <br /> PHASE I FOR DFjPARTMENT USE ONLY Lodi, Cc@ifor nic 95240 <br /> APPLICATION ACCEPTED BY , DATE _07 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION VPHA AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. -I-74 <br /> 3/76 240 4k <br />