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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Q <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 074-02,0-1j, <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 /> �8,� 0 4 . <br /> JOB ADDRESS/LOCATION L, ,Pap c.c -- �] C _ (���� RACT <br /> Owner's Name l� CZ L r, ,� Phone 6_edg)379- J_00 <br /> Address - 166Z,15:� __Dez L-111 ZMZ-La City Sl -7zj3-S <br /> Contractor's Name Sag Joaquin pump CO. € License # 3'1,037X Phone 3 <br /> TYPE OF-WORK (Check) : NEW WELL / / DEEPEN / RECONDITION /_/ DESTRUCTION /7 _ p <br /> PUMP INSTALLATION / UMP REPAIR / / 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 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 Si7.v -,yoXetJ Lip h C et2Sp�/� <br /> Type of Pump tt� �, H.P. <br /> _ iQ LvcnTiU-� DF RuAcj9 1�,*7 Qf�o 4Vel/ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work 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 INSPEC'T'ION <br /> PRIOR TO GRO G AND A FINAL TNSPECZJO <br /> SIGNED TITLE San Joaquin Pumpp�-_ <br /> RAW PLOT PLAN ON REVERSE SIDEXDivision of San Joaquin Sulphur Can <br /> FOR DEPARTMENT USE ONLY111 IT atramen o St. <br /> PHASE I Lodi, California 95240 <br /> APPLICATION ACCEPTED BY ` 14! DATE _S5 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY A DATE Z�.?_ � <br /> E H 1426 Rev- 1-74 <br /> • ��77 2M <br />