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SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> FOF�OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Imo. _Z2_2 <br /> (Complete In Triplicate) QS'( - 130_r�F <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. 182nd the Rules and Regulations of the San Joaquin Local Health District. <br /> Cpc•! � cc .�o,erN Since iv�wF.fc� R t� �/z M��e E.os r OF <br /> JOB ADDRESS/LOCATION .t©cccsT r2Fd P-9 CENSUS TRACT <br /> Owner's Name l {„�,, TyO- Kt_TL'#G,C'S I467„_ Phone <br /> Address f 67, /_00/ City Gp/J/ <br /> Contractor's Name San Joaquin Pump Co. License # Phone -$ 7 <br /> wV5: . t- . <br /> TYPE OF WORK (Check) : NEW WELL / J DEEPEN / / RECONDITION /__/ DESTRUCTION /_7 <br /> PUMP INSTALLATION /IPUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> W <br /> b <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 �A.,� Sc,r�a3�..,j Pu-ik - <br /> Type of Pump S 4e.6 AIF RS,,!3/c __....,----- H.P. / a. he fa <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: J / State Work Done <br /> .7ESTRUCTION 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 /> information is true to the best of my knowledge and belief. <br /> San Joaquin Pump Co. <br /> SIGNED A �t TITLE (Division of San Joa ain Sul hur <br /> (DRAW PLOT PLAN ON REVERSE SIDE) 711 N. Sacramento St. <br /> ..' FOR DEPARTMENT USE ONLY Lodi, Ca,ii-TMO 95240--f--� <br /> PHASE I 7b <br /> APPLICATION ACCEPTED BY /%' • �� DATE <br /> ADDITIONAL COMMENTS: 10 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL_ INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4'r!' DATE AC=Rw <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />