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R <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT-. <br /> FOE OFFICE USE: (f" 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. j��/J� 1Q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - Date Issued <br /> -(Complete In Triplicate) <br /> �� <br /> Application is hereby made to the San Joaquin Local Health Dis.trict -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 /> JOB ADDRESS/LOCATION /'-5-7,3o CENSUS TRACT <br /> Owner's Name Phone —(}2 l <br /> i <br /> Address f ,S`73 O ,V. Z0 DOCS T Tie A�Q City Lo 0 / <br /> Contractor's Name Son ;10aquin Pump Co. License # Phone 6�y7 <br /> (Division of Son Joaquin bulphurCo.) <br /> v..la l <br /> TYPE OF WORK (Check) : L N � / / DEEPEN /_/ RECONDITION / / DESTRUCTION /7 - l <br /> PUMP INSTALLATION '/ / PUMP REPAIR /c7-;:-PUMP REPLACEMENT /7 <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 U <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 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: " <br /> /::�'State Work Done �.ege,Ve-7 <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 INSPECTION <br /> PRIOR TO GROUTIHq=gD A FINAL INSPECTION. <br /> SIGNED TITLE Son Joaquin PUMp Co. <br /> W Pi, T' PLAN 'ON RE ERSE SIDE) Frisian a an' aquin' !phut <br /> FOR ' EPARTMENT USE ONLY <br /> PHASE I Lodi California 9,5240 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE i <br /> E H 1426 ,:.Rev. 1--74 376 2M � <br />