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0 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ME-OFFICE USE: � 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ���a 76}0 <br /> A <br /> THIS PERMIT-EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> i. (Complete In Triplicate) <br /> I� Application is hereby made t11R 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 /> JOB ADDRESS/LOCATION s .P�''J� 'v�4 �iCT Mi CENSUS TRACT <br /> owner's Name el, GG Phone <br /> Address 12Zr5�'- Zbwee S/'7C_,P_�'Yl9�jCJ� City �y <br /> �[ &0,9/ <br /> San joagti+m Pump Co. License # ,j10;37d Phone ' ' 517/ <br /> Contractor's Name ' <br /> 711"N k"wrem1b.145-st <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / . RECONDITION '/ /%.- DESTRUCTION /rT <br /> PUMP INSTALLATION/ / PUMP REPAIR/� PUMP REPLACEMENT /� <br /> Otheri / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEW'AGE'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE +ERIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> M 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 -� <br /> , of Casing - - <br /> Irrigation ' `Gravel Pack Depth of Grout Seal <br /> I Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor ' <br /> Types of Pump H.P. <br /> PUMP REPLACEMENT: / / '; State Work Done ' <br /> { <br /> PUMP .REPAIR:,_ ,/State .Work£Donei9�r� <br /> w" ..�.�� /±�1 _ � . . <br /> DESTRUCTION OF'WELL: We11 D <br /> iameter 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 <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 /> I PRIOR TO GROUTING AND A F• NSP ON. San Joaquin poo Co. <br /> SIGNED TITLE <br /> i D W . PLAN ON RE E'RSE SIDE) <br /> aq a9uin S�tfp�ur <br /> 5— <br /> R <br /> R DEPARTMENT USE ONLY Lodi, Ca!ifornio 93210 <br /> PHASE I DATE - 2 <br /> APPLICATION ACCEPTED BY <br /> ' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY ! DATE INSPECTION BY _ DATE 1/ -f <br /> 3/76 2m <br /> E H"1426 Rev. 1-74 <br />