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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. �6_I 33jo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to 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 I '� fQG Suu TM OF 114AeveY EtST$i &W,5f4 CENSUS TRACT ' <br /> Owner's Name <br /> . Phone 3 -376) <br /> Address r L-A <br /> city &v/O <br /> Contractor's Name Sorg Joaquin Pump Co. ���71 <br /> License # phone <br /> {Division of San Joaquin 5uphur Ca. i <br /> TYPE OF WORK (Check): � wci ` i;''°/%�­bEEPEN _ <br /> _/ / ' RECONDITION DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /!PUMP REPLACEMENT /_ <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER :LINES <br /> PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER # <br /> INTENDED USE \ <br /> TYPE OF WELL <br /> industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> Domestic private— -Drilled-- - Dia;.-of--Well--Casing <br /> . <br /> Domestic/ ublic _ ,. . <br /> P _ _ Driven..: 's Gauge of Casing (� <br /> Irrigation Gravel Pack Depth of Grout Seal \ n <br /> Other Rotary Type of Grout N'3 <br /> ' ,Other Other Information v <br /> PUMP INSTALLATION: Contractor,. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: f <br /> 11;;K State Work Done f,j 2,p�{� ,�dQS4, <br /> ESfiRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 <br /> San J©Uquin PuMp Cc. <br /> .•1 TITLE (Division of son Jon i e <br /> (DRAW PLOT PLAN ON REVERSE SIDE 71 N. <br /> 5scran�e i'n r,, r- <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY Lodi, caiiforraia 9Sa�p <br /> APPLICATION ACCEPTED BY DATE � <br /> ADD � <br /> ITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI PHA /I INAL INSPECTION <br />[NSPECTTON BY DATE INSPECTIONBY ' DATE � p <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 IM <br />