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� k <br /> fes' 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. ?(- �s_ <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z2_f 7e <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 /> CA S-Td F r�'�p c 7/o.0 Z I-V .c%P_7,4 o f <br /> JOB ADDRESS/LOCATION G N 6_10S 7- F Qi - 5H a _ CENSUS TRACT { <br /> Owner's Name CLE h uo llJ F R UA - _ Phone 361,- 2. 73Y <br /> Address C? j t � <br /> Son —4 = A/1� G� City L_ot2 / <br /> ys Joaquin Pump Co. <br /> Contractor's Name - License # Phonele,-1141; sulphi., <br /> _ Lodi, Colifar�i�S240 , <br /> TYW OF WORk (Check) : NEW WELL /AL/ —DEEPEN`'/ '. RECONDITION /? DESTRUCTION /� <br /> PUMP INSTLATION / / . PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK `ti,j, y� SEWER LINES PIT PRIVY 0 <br /> SEWAGE DISPOSAL FIELD '_4 CESSPOOL/SEEPAGE PIT OTHER <br /> Q� <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 w -_ _..Gauge_of_Cas_ing <br /> irrigation i Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout _ <br /> IE Other Other Information <br /> 1 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done,f `C_� ICIk W� �i f� SLl�l�7� rale <br /> PUMP REPAIR: / / State Work Done <br /> 1 ,DESTRUCTIONOF 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. San Joaquin Pump Co. <br /> 1, YL/ (Division of San Joaquin Sulphur Co.) <br /> SIGNED TITLE711 N 5nrmmP_ntn St <br /> (DRAW PLOT PLAN ON REVERSE SIDE +- tee; <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I, nn <br /> APPLICATION ACCEPTED BY <` 0� DATE IL <br /> G �6 <br /> ADDITIONAL- COMMENTS <br /> PHASE II GROUT INSPECTION PRASE III INAL INSPECTION <br /> INSPECTION BY EDATE INSPECTION BY DATE lidl <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E 7/72 IM <br /> H 1426 <br />