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3 <br /> a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOR;OFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �5�6 <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.eribed. Thie 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 c_,� Ti-� v p ew.c �J CENSUS TRACT <br /> Owner'a Name L. Eco A..) ��?- <br /> •- � �L— _,_.,...._,....„,,.,..._.,. Phone- 9 /zZ7 <br /> Address J <br /> City 600 / <br /> Contractor's Name San Joaquin Pump CO._ <br /> License Phone <br /> {pIY45iQR 0 a <br /> TYPE OF WORK (Check): NEW WELL' ' DEEPEN /? RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR '/-7—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 WELT. 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 T <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 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . /17�" S tate Work DoneaG/ <br /> PUMP .REPAIR: / / State Worts Done <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 GROUTING AND A FINAL INSPECT R. <br /> SIGNED TITLE Saye Joaquin Pump Co. <br /> (DRAW PLOT PLAN ON REVERSE SIDE (M sion of Sun Joaquin SUIPROY <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i Lodi, C®iifnrr�io 95240 <br /> � � - . <br /> APPLICATION ACCEPTED BY DATE 16ihz <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTIOW PRASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE <br /> E H 1426 Rev. 1-74 ' ``�' Y r '7 <br /> . - �� 4/75 2M-- - - <br />