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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,6_� 7jo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date` Issued � <br /> (Complete In Triplicate) 06?- os0--03 <br /> Application is hereby made to the San Joaquin Local 11ealth: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 'Ordinan ce FNo. 1862 and the Rules and Regulations of the San Joaqufin Local Health District. <br /> l(o l L L c'J �24/14" <br /> JOB ADDRESS AOCATIO z <br /> �,gsr a ►c rna.� `� /z"' '� <br /> al �•qv r CENSUS- TRACT <br /> Owner's1Name ug, P Phone <br /> Address, <br /> Contractor's Name San Joaquin Primp Co, <br /> License # -37S-Phone 9-S 1/7/ <br /> acramento St. <br /> ' Lodi, California 95240 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN/_7 RECONDITION <br /> T DESTRUCTION J T <br /> i PUMP INSTALLATION/7 PUMP REPAIR /�IsUMP REPLACEMENT J]" <br /> l • Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY rEN1 <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 BY: <br /> PUMP INSTALLATION Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: . %/ State Work Done <br /> PUMP REPAIR: tate Work Done <br /> PES-TRUCTION 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 INSP ION. <br /> SIGNED ( TITLE San Joaquin Pump Co. <br /> DRAW PLOT PLAN ON REVERSE SID$�'����or Son ��aaui4� c.� „" <br /> 711 a r <br /> F94 DEPARTMENT USE ONLY Lodi, Colifarnio 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BY WDATE ' `T� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTIQNk <br /> INSPECTION BY DATE INSPECTION BY DATE o <br /> E R 1426 Rev. 1-74 rr h/75 2M <br />