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v-_ SAN J'OAQUIN LOCAL HEALTH DISTRICT OS�C«-Z�fl Zb <br /> k FOE OFFICE USE: 1601 E. Hazelton Ave.'," .Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;7Z- 1fd_,PO <br /> THIS PERMIT, EXP.IRES 1 YEAR FROM DATE ISSUED Date. Issued Z�� <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 Ordinante=NO. 1862 and the Rules and Regulations of the San--Joaquin Local Health .District. <br /> JOB ADDRESS/LOCATION A/ m'/e F,.sf er Cppe)CS 4m11C ,Sm,7V 00r /2 CENSUS TRACT <br /> 2b , f�l�f r Z <br /> t Owner's -Name ' G� -27"+/' Phone 34J-4Z67 <br /> Address / 6 & /S /2 City Lo_o <br /> Contractor's Name ; 'ion Joaquin Pump Co. { <br /> G r Cu. License #3j& 7ff Phone 7 <br /> M • <br /> onento St. <br /> Lodi, California 95240 <br /> '4-TYPE- OF WORK (Check) : NEW WELL' / / DEEPEN DESTRUCTION -/77 <br /> PUMP INSTALLATION/ / PUMP REPAIR/L/- PUMP REPLACEMENT /7 <br /> Other J-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> r SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ` PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL s <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 _ YDepth' of Grout Sear <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical , Surface Seal Installed By: <br /> PUMP INSTALLATION: ' . Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done.-- - <br /> PUMP .REPAIR: /DJ-state Work Done <br /> � <br /> AES•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 -GROHJ=gG AND A FINAL INSPECTI ori loaquin PUMP Co, <br /> SIGNED TITLE (Division of Son Joa vin <br /> DRAW PI T PLAN 'ON RE FRSE SIDE Sdcresmentb <br /> --FOR DEPARTMENT USE ONLY- -- °�' arnia 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE <br /> I;;/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION"BYIV <br /> DATE <br /> E H 1426f Rev. 'I-74 �" <br /> 3/76 2M <br />