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�j r � 4 <br /> r <br /> C- / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR-OFFICE USE. ✓ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466- 6781 <br /> APPLICATION FOR WELL CONSTRUCTION'OR PUMP PERMIT Permit No. 7�-SG1�D <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) r <br /> Application is hereby-made to the"San Joaquin Local Health District for a permit to construct M <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No: 1862 and'Ithe Rules and Regulations of the San Joaquin Local Health District. <br /> AGra+r. o 0 InA-V-� 2Q ,vC-R.Tf! O- � �i.gNrl <br /> JOB ADDRESS/LOCATION .�S .i o e. �` CENSUS TRACT <br /> Owner's Name 3 <br /> • �� Phone + <br /> Address -2 13 7 A), <br /> -L.►-J cit _ . . <br /> Contractor's Name San Joaquin Pump Co. ^� <br /> IYISIRn U nn ouqu, ,y„ ,, License # �� Phone <br /> Lodi Caiifarnia 95 <br /> TYPE OF WORK (Check) : MW WELL / J DEEPEN /_/ RECONDITION "/� DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /� YUMP REPLACEMENT /7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER a <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ff ,' <br /> Industrial Cable Tool Dia. of Well Excavation W <br />_ Domestic/private Drilled w Dia, of Well Casing <br /> Domestic/.public Driven ;* Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other„_Information. <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> i <br /> PUMP REPAIR: State Work Done lal <br /> ESTRUCTION 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. <br /> SIGNED 1 TITLE Ston Joaquin Pump CO. <br /> an Joaquin Sulphur Co.) <br /> (DRAW PLOT PLAN ON REVERSE SIDE l N. Sacramento St. <br /> FOR DEPARTMENT USE ONLY Lodi, California 5 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY e--,f <br /> 414& DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />