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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone.: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 1 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> VorZTl/ S/Ac ©f= .C<<3e�, .&Z) � ��qsT' Get <br /> JOB ADDRESS/LOCATION jS ej_1 04,(_A ►Z b C-6 ,a Gk. CENSUS TRACT <br /> Owner's NameAlt)9 40A10 i00/402-C . Phone LZ_3 <br /> i <br /> Address (1 Z Iq U City _C-4e,7 <br /> Sari Joaquin Pump Co. <br /> Contractor's Name _- _ CQ License # Phone V5 4&-71 ' <br /> 711 W!, Sqrreimpng <br /> ' -Lodi, Cal ifo:rn�5240 _ <br /> TYPE OF WORK (Check): . NEW WELL J / DEEPEN /__/ RECONDITION /7 DESTRUCTION /_7 <br /> `` PUMPOINSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> f Other <br /> � T <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> G SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' -- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation Q <br /> Domestic/private Drilled Dia, of Well Casing Q <br /> Domes tic/public _-- Driven Gauge of Casing <br /> irrigation i Gravel Pack Depth of Grout Seal <br /> Other 4 Rotary - - Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump IL <br /> H.P. <br /> f PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: _ / / .State Work Done 1-C S 7 /,C�/3 .�! <br /> ' - <br /> i .RESTRUCTION 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. <br /> San Joaquin Pump Co, <br /> SIGNED c TITLE (Division of Son je_oquin Futphur Co.) <br /> (DRAW PLOT PLAN ON REVERSE SIDE 711 41 """ <br /> FOR DEPARTMENT USE ONLY <br /> ge- <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 617 <br /> ADDITIONAL COMMENTS: f <br /> PHASE Ii* GROUT INSPECTION.- PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />