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SAN JOAQU:IN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif . <br /> Telephone :` (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP <br /> PERMIT Permit No. , � <br /> f <br /> THI19 .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date .Issued <br /> (Complete In Triplicate) <br /> Application is hereby made t.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 sand the Rules and Regulations of the San Joaquin Local Health District. <br /> Z <br /> / '3 �3 �W ENSUS TRACT <br /> JOB ADDRESS/LOCATIONC� f, 20an <br /> Owner's Name eJ `C G Phone _C��- f <br /> �1 a City <br /> 4:� <br /> Address <br /> Contractor's Name <br /> 5a�g36 "u TI PUMP Co. License # &, ,Phone 5;,12/ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br />[ <br /> Other ./1.1 <br /> / -V <br /> r DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY <br /> SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE 1.-- PRIVATE DOMESTIC 'WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial =1 Cable Tool Dia. of Well Excavation <br /> Domestic/private It Drilled Dia. of Well Casing <br /> Domestic/public fl <br /> Driven Gauge of Casing C <br /> Irrigation ;! Gravel Pack Depth of Grout Seal <br /> Cathodic Protection f Rotary Type of Grout <br /> Disposal I Other Other Information <br /> .surface Seal Installed B <br /> Geophysical <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type 'of Pump <br /> �1 l� - fAs puJw <br /> PUMP REPLACEMENT: <br /> / #State Work Done �.�IG�� 7 � -� 3 w�T <br /> PUMP -REPAIR: / _/ State. Work Done <br /> DESTRUCTION OF WELL: WelllDiameter Approximate Depth <br /> Describe Material and Procedure <br /> II hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Californialpertaining to or regulating well construction. Within FIFTEEN DAY <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 thelwell and notify them before putting the well in use. The above <br /> information is true to the 'best of my knowled e and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING FINAL I SPEC i0 San JOCtquin Ppirp CO. <br /> SIGNED TITLE _ „f <br /> D LOT PLAN ON REVERSE SIDE) menta 5t. <br /> FOR DEPARTMENT USE ONLY Lodi, Colifarnio 95140 <br /> i' PHASE I s <br /> DATE /;o/-- <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE i I/FINAL INSPECTION <br /> PHASE II GROUT INSPE ION DATE <br /> INSPECTION BY., DATE INSPECTION BY <br /> k <br /> 6,177 _ 2M <br /> P U 1h9A RPu- . 1-74 <br />