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SAN JOAQUIN LOCAL HEALTH. DISTRICT <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. .7296 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued &;2-2.2 <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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .5/S eiw A 2 .,",Ae 4Jfo 0R1,1S 60,L-J P-04-J, CENSUS TRACT Ol.3 -O'7©-02_ <br /> Owner's Name Phone <br /> Address ZZ q w tU�r� , D�ti cS City Lo 0 / <br /> Contractor's Name San Joaquin Pump Co. License # ZgPhone 3 -8 7/ <br /> (Division ot San Joaquin 5ulphur o. <br /> - --- i <br /> �A; C -s_f ,.:a 9,x21-0 <br /> TYPE OF WORK (Check): NEW iEL 7DEEPEN /% RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / UMP REPLACEMENT / <br /> Other /_7 O <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 '(G <br /> - Disposal Other Other Information (� <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump !! H.P. <br /> PUMP REPLACEMENT: . /tate Work Done tO., ZS~ &Z81-&5 <br /> PUMP .REPAIR: Cl- 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 /> information is true to the best o€ my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUILKLAND A FINAL INSPECTION <br /> SIGNED TITLE San Joaquin Pimp Co. <br /> RAW PLIOT PLAN ON REVERSE SIDE)_M"'ision of-Sah a1 quin ga! huh <br /> FOR DEPARTMENT USE ONLY acecEnerity St. <br /> PHASE I Lodi, Ccfifarnia 91240 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - - - 7? <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />