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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 0 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES f YEAR FROM DATE ISSUED Date Issued - 71z 74K <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�a/n 7the ule and Re lations of the San Joaquin Local Health District. <br /> JOB ADDRESS f i7" 0 <br /> 900-st 7� -roe -!,-R ea- !wr <br /> /LOCATION -rCENSUS TRACT <br /> Owner's Name ..� Z 6e�I.e& _.. ..,-._ Phone 6 `I <br /> Address 7 N. Cit GC)O/ <br /> Contractor's Name Son loanu; ; Pumn, n. License 37 <br /> Ahone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /v/ State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESmtRUCTION 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 wellmconstructi.on. 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A. IN$PECT10,,,- 7 Son Joaquin Pump Co. <br /> SIGNED TITLE visman of San <br /> (DRAW PLAN ON REVERSE SIDE) " ' "" ' <br /> PHASE I FOR DEPARTMENT USE ONLY Lodi, California 95240 <br /> APPLICATION ACCEPTED BY ' DATE ;2 ✓ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE`"--, ], :.Z Z <br /> E H 1426 Rev. - I-74 <br /> �� a��77 . 2M <br />