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e 1 €fz, <br /> SAN JOAQUIN LOCAL HEALTH 11TRICer' a <br /> ,FG1"OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif, ` y <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?(-S416)" <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Issued 7,-9 <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 /> $'6 u T.4 S"aC or !sF f�/��ke`! .1 •tea.f� E�_s y� �/', <br /> JOB ADDRESS/ ,OCATiON .�L T�,� ��.�,, CENSUS TRACT <br /> Owner's Name _49 111V ,e Phone 7 <br /> Address � le �1.va.ti1 e�-t) City Q/ <br /> Contractor's Name San Joaquin Pump Co. <br /> tBiftlull of 52.2 106'"i I Gulp!"I G. License # Phone Ul <br /> Lodi Calif 95240 <br /> TYPE OF WORK (Check): NEW WILL / DEEPEN /? RECONDITION /7_ DESTRUCTION J <br /> PUMP INSTALLATION J / PUMP REPAIR'/ j <br /> PUMP REPLACEMENT f7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER q� <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 'B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP :REPAIR: /Z,/!State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with a1.1 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 myknowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPE ION. <br /> SIGNED TITLE San Joaquin Pump Co. <br /> DRAW PLOT PLAN ON REVERSE SIDE , -1--wonto St <br /> < c <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Lodi, Caiifaxnin 95240 <br /> „• <br /> APPLICATION ACCEPTED 13Y f DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIIFIM INSPECTION <br /> INSPECTION BY DATE:, INSPECTION BY DATE , <br /> E H 1426 Rev. 1-74 11/75 PM <br />