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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-678 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / 7_7V <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct j <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 <br /> � District. <br /> JOB ADDRESS/LOCATION"J CENSUS TRACT <br /> Owner's Name Phone <br /> Address_ /�1/��(� // ;L/)�y/� �'� _ T City <br /> r <br /> San Joaquin Pump Co. s <br /> Contractor's Name (Division of San Joaquin Sulphur Co.) License # Phone <br /> 711 N. Sdcramento St. <br /> Lodi, Calitarnia 52- <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION RECONDITION /_ / DESTRUCTION /_7 _ <br /> PUMP INSTALLATIONf�/ / PUMP REPAIR /p/f 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 7. Dia. of Well Casing <br /> Domestic/public i#DAven Gauge of Casing ` ,� <br /> Irrigation Gravel Pack Depth of Grout Seal C-. _ `�k . <br /> Cathodic Protection Rotary Type of Grou„tJ .4A 4 A I <br /> -Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor l,L \~ <br /> Type of Pump Pte,(?/SSS &&.doy! H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /,estate Work DoneA� �,� ' <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 puttingthewell 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 FINAL INSPECTION. Son Joaquin <br /> SIGNED _ TITLE (Division of San Joagdln sulphur co!) <br /> (DRAW PLOT PLAN ON REVERSE SIDE) 1 acr v ” <br /> FOR DEPARTMENT USE ONLY L0010 <br /> PHASE iJ APPLICATION ACCEPTED BY � DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION WPHASE III FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY rDATE/ / <br /> F' H 1 G7F, 17c.i l_7L <br /> n/l.7 - 2M <br />