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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOB OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- r / �a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued A Z7 <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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. j <br /> JOB ADDRESS/LOCATION �' � u leJ �G•u.�,Pi'ic /!fes d L���r CENSUS TRACT <br /> f <br /> Owner s. Name Phone ,362-2 S 16 --- <br /> Address .2 7 3 clS- IV, City G L } <br /> 1 <br /> San Joaquin Pump Co. <br /> Contractor's Name (Division of Sort Joaquin Sulphur Cyj License # Phone <br /> 711 N. 5acromento 5t. i. <br /> L001, a arnia 95240 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / UMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 1 <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 <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 H.P. <br /> PUMP REPLACEMENT: / / State Work. -bone <br /> PUMP .REPAIR: ate Work Done e < to ISS S uA e2b ozc <br /> d '026 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> qn� Describe Material and Procedure <br /> I hereby agree to comply with all laws ,-and regulations of the San Joaquin Local Health District <br /> I and the State of California pertaining to or regulating well '-construction. Within FIFTEEN DAYS <br /> C 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 A FILIAL INSPECTION. an Joaquin Pu <br /> SIGNED � TITLE P 'Ca. <br /> W I'I T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY Lodi, Califoxnic 95240. <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO11. PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY E DATE -7, <br /> F u IL9A tza.r_ 1_74 <br /> 3/76 2M <br />