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t 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <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. �7 <br /> i THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssudXC 22 1971 <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of ,the San Joaquin Local Health District. <br /> �7 h <br /> + JOB ADDRESS/LOCATIONl:!� CENSUS TRACT <br /> Owner's Name <br /> C9G1/I <br /> Phone3Z!". t �7-- _ <br /> I� <br /> Address Q Q/1 City ,��,D/ <br /> � <br /> Contractor's Name $I�n Jona�uin AuraACO. License �� Phone <br /> - ��- <br /> TYPE�'OF'WORK'^`(-Check)-: ' .NEWTWELL DEEPEN / / RECONDITION III DESTRU_CT.ION_ / <br /> PUMP INSTALLATION / / PUMP REPAIR /yUMP REPLACEMENT � <br /> 0 ther <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -' PIT-PRIVY C <br /> �kSEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE—PTT _ OTHER <br /> 1PROPERTY 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 i Other Other Information <br /> Geophysical I Surface Seal Installed By : <br /> p i <br /> PUMP INSTALLATION: i Contractor <br /> I! Type of Pump _ H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / 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 <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 GROU ANDREA FNA ._ TSara Joaquin'Pmp Co. <br /> SIGNED ': ' •Y _ ._ TITLE (p;,,!q ( su,, E " � <br /> IM. (DRAW PLOT PLAN ON REVERSE SIDE) ,,rC1 "� hktr � <br /> FOR DEPAR'T'MENT USE ONLY Lodi, California 95290 <br /> PHASE I ' -may <br /> APPLICATION ACCEPTED BY DATE I - Z <br /> ADDITIONAL COMMENTS: I1' <br /> PHASE Il):GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY 11 DATE INSPECTION BY — -- DATE ,;` •�- ��oP <br /> ,. ,Ik <br /> E H 142"6' - Rev 1 7 4� „ - ,rte- <br /> 0/77 2P9 <br />