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` GSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FYCE USE: V601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77� <br /> THIS PERMIT EXPIRES I YEAR FROM .DATE ISSUED Date Issued <br /> (Complete In. Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District. ,for. e 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 Joaquiw Local Health .Distriet. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name --- Phone �,�� -3 V4 / <br /> Address City ©/a if <br /> Contractor's Name _ San .Joaquin Pump Co. _ ...___._� License # -3)()3 -Phone <br /> (Division of San Joaquin Sulphur Co.) <br /> TYPE OF WORK (Check): NEVA" AVM 9MPEN •/_7 RECONDITION ` DESTRUCTION` /-7. <br /> PUMP INSTALLATION/ / PUMP REPAIR/PUMP REPLACEMENT j J <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 BX: <br /> PUMP INSTALLATION: Contractor <br /> Type of Puipp H.P. <br /> PUMP REPLACEMENT: . / / State Work Done 1 `� <br /> PUMP .REPAIR: t lREPAIR: / State Work Done r9t�a� ut rh..ri T-O 3 tj P 7Q- 4giye e�" <br /> DESTRUCTION WELL: Well Diameter Approximate Depth <br /> _ - -ION OF _ <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 INSPFCTION. <br /> SIGNED TITLE San Joaquin Pump Co. <br /> -11 DRAW PLOT PLAN ON REVERSE SIDE (Division of San Joaquin u p ur o. <br /> FOR DEPARTMENT USE ONLY ` <br /> PHASE I Lodi, Caiifarnia 95240 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTN <br /> INSPECTION BY DATE INSPECTION BY DATE A <br /> s E R 1426 Rev. 1-74 4/75 <br />