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SAN JOAQUIN LOCAL HEALTH DISTRICT f <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. �G�a <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 /> ��717 A�" �tf6�ELJ f rl aS ' RtAiila6 Reoi- , SQu—rd oh <br /> JOB ADDRESSAOCATTON t3 rt_"),6- Dee-v ,_ - -.2_ca _X> CENSUS TRACT <br /> Owner's Name Zj o M.til F L E 1{m n 1c/ Phone J01-307 <br /> Address Al /Vl � q9 City Z-00 <br /> Son Joaquin Pump Co. r} (� (YJ` <br /> Contractor's Name (Division of San Joaquin Sulphur Co.) License # Phone -?d/U T 71 <br /> 711 N. Sacramento St. _ # <br /> Lodi, Cafitctrnia 4 <br /> TYPE OF WORK (Check) : . NEW WELL / / DEEPEN_ /,/� RECONDITION /_7 DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION " PUMP REPAIR / / PUMP REPLACEMENT 0 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled 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 sA j J 0 A Q u c-J pct nj e_L , <br /> c <br /> Type of Pump Sc.t/3mc2(�rl3Zc.: S��^ II- /Pr� TH.P. � <br /> PUMP REPLACEMENT: / // State Work Dane QL <br /> PUMP REPAIR: / / State Work Done - -� <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 there before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> Son Joaquin Pump Co. <br /> SIGNED TITLE (Division of San Joaquin Sulphur Co.) <br /> (DRAW PLOT PLAN ON REVERSE SIDE 7!1 N. Sacromenro St. <br /> FOR DEPARTMENT USE ONLY CUM, <br /> PHASE I ! J <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIM v PHASE UjF.I-NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT. INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />