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SAN J'OAQUIN LOCAL HEALTH DISTRICT <br /> FCT OF.','-',ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 �� a <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued AIA17`� <br /> (Complete In Triplicate) <br /> Application is hereby matte 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 i <br /> County Ordinance No. 1862 and the Rules-and Regula ron of�thesSan Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION o T `e F ENSUS TRACT _ <br /> Owner's Name Phone <br /> Address City 49!,991!S2 <br /> Contractor's Name �o� JoaquinPup`Co. License #,,31 6,3-7 Phone <br /> c3(og�'�2L._ i <br /> CSt <br /> i <br /> Lodi, California 95240 _ <br /> TYPE OF WORK (Check) : NEW WELL -/-7 DEEPEN / / RECONDITION / / DESTRUCTION 17 <br /> PUMP INSTALLATION/ / PUMP REPAIR/bf PUMP REPLACEMENT /-7 , <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 I <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 i <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: /i / State Work Donel <br /> P1F. <br /> TPUMP .REPAIR: /State Work Done �p _) �Z2 !_ <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 thewell 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 D A FINAL IN ECTION. <br /> SIGNED TITLE Son Joaquin Pum Co. <br /> ivision of 5ai�Joa <br /> . DRAW Ph T PLAN 'ON REVERSE SIDE) quia'Stilp4ur`Co. <br /> FOR DEPARTMENT USE ONLY III IN. 3acramento St. <br /> PHASE I Lodi, California 524 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIbN PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE/,,?-- -, 7 <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 ; <br />