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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: 1601 E. Hazelton 'Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.ZL42' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued-3. ; <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 Heal.th, District. <br /> JOB ADDRESS/LOCATION 28082 N. NICHOLS RD ALT S CENSUS TRACT <br /> Owner's Name GLENN R. PETERSON Phone <br /> i <br /> Address 880 SAN RAMON WAY City SACRAMENTO }} <br /> Contractor's Name T^mmmn Pump CO. License # 310378 Phone 369-8471 t <br /> a <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION )o 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 SAN JOA UIN PUMP CO. , LODI <br /> Type of Pump TURBINE H.P. 40 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G AND FINAL INS UN. $nn Joaquin Pum <br /> SIGNED TITLE fp Co. <br /> (DRAW PLOT PLAN ON REVERSE SIDE) 860 E. PIME STRE= <br /> FOR DEPARTMENT USE ONLY ,lel California%M$% 952 <br /> PHASE I <br /> 40 <br /> APPLICATION ACCEPTED BY ��eA DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II ./FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE T, d, y j' <br />