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, SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. r <br /> ;a` # <br /> Telephone: (209) 466--6781 <br /> 1. APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> } (Complete In Triplicate) tJS� r <br /> Application is hereby made to�the San Joaquin Local Health District for a permit tro construct <br /> and/or install:lthe' 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 /> JOB ADDRESS/LOCATION �:dJeouzc 4 T %!� �-�'� L1�f/1�J CENSUS TRACT <br /> 1 <br /> Owner's Name F C �i°9 Phone <br /> f <br /> Address <br /> City �CA <br /> contractor's Name 4"--,) L` License #,Y-Off- Phone, <br /> IL _ <br /> V� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION DESTRUCTION DESTRUCTION /� <br /> i j PUMP INSTALLATION / / PUMP REPAIR /v�' PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTICTANK SEWER LINES y PIT PRIVY <br /> SEWAGE-DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTICIMELL PUBLIC DOMESTIC WELL <br /> � O E <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool <br /> Dia, of Well Excavation <br /> I Domestic/private t Drilled Dia, of Well Casing <br /> I' Domestic/public Driven Gauge of,Casing <br /> 11. Irrigation ..._:! —Gravel -Pack_ • tea. -Depth of. .Grout.-.Seal <br /> J Cathodic Protec-tion i. Rotary Type of Grout <br /> Other.,, Other Information <br /> Gj� Disposal i . <br /> I Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor, <. ; ` <br /> j Type of Pump H.IT. <br /> PUMP REPLACEMENT: / / State' Work Done <br /> PUMP .REPAIR: F' lvr <br /> ate Work Done J&A Ad u <br /> rox <br /> A imate Depth <br />•: DES•TRUCTION OF WELL: Well Diameter pP p <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 -611 and notify them before putting the well in use.. The above <br /> -iinformation is true to the best of my knowle e and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING INAT., I6PE rRTITLE SAN JOAQUIN PUMP COMPANY <br /> IGNED (D PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPART NT USE ONLY P. Q. SOX 201 <br /> E�xASE I Lodi, raa nia <br /> M� <br /> APPLICATION ACCEPTED BY 17A <br /> 4. .ADDITIONAL COMMENTS: 'a <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY `, DATE �-� <br /> - 6/7.7 _ 214 <br />