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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FC! -OkFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - p A�J <br /> X7K:1cP J�? <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued, -- g!'& <br /> Appl'f�-27,- I, (Complete In Triplicate) 0�5=t70-1� <br /> ication 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 "" SGS /P� V2S� --- ENSUS TRACT <br /> Owner's Name Kn L Phone 2.3 V-22-00 <br /> Address Ilg a i'S_ _AAI SE.2f' `•�QQ...._ _�� / �/_�/71/1.c� L� City G4,0/ <br /> Contractor's Name License � 3f- 7�� _ _ , <br /> i <br /> TYPE-OF-WORK-t,(Cheek) NEW WELL /!- -,DEEPEN-/-/- RECONDITION_/-,/_._DESTRUCT.ION_ <br /> PSr.. :ION PUMP REPAIR / / PUMP REPLACEMENT /? <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS- <br /> Industrial Cable Tool Dia. of Well Excavation <br /> `/ Domestic/private Drilled Dia. of Well Casing 2" <br /> Domestic/public Driven Gauge of Casing /0 r <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information s <br /> Geophysical Surface Seal Installed By. <br /> PUMP INSTALLATION: Contractor <br /> �2 T�.g_�u r.rJ Pcrrl t fl C.O � G a D�� �'s4- .• •• •„_,._•, <br /> Type of- Pump --z 4 4_ r��.2 S rC1G H.P. <br /> PUMP REPLACEMENT: /�/ State Work Done <br /> PUMP .REPAIR: / / . State Work Done <br /> DESTRUCTION 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 /> informatio is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING AND A FINAL INSPECTION. Sari Joaquin Pump Co. <br /> E SIGNED, TITLE Qi i i r <br /> D W PL T PLAN 'ON RE FRSE• SIDE 7]1 <br /> FOR DEPARTMENT USE ONLY Lodi, Cal:farnia 95240 <br /> PHASE I Z <br /> APPLICATION ACCEPTED BY DATE ,.. ..r <br /> ADDITIONAL. COMMENTS: 10, <br /> P E II GROUT INSPECTIO F /FINAL INSPECTION`. =' <br /> INSPECTION BY. DATE INSPECTION BY DATE <br /> _ E H 1426 Rev. 1-74 <br />