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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. 7, Al. /J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued q -77 <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 Health District. <br /> JOB ADDRESS/LOCATION 1 J 5 S o ,V -/ CENSUS TRACT <br /> Owners Name Phone <br /> i <br /> Address 2,(S w Ly s-/2 City Q/J <br /> Contractor's Name San Joaquin Pump Co. License #31Q3Phone Sf71 <br /> Sm.. _ ,� i <br /> -LodiiZahferr;aJS240L.- _ <br /> TYPE OF WORK (Cheek) : NEW WELL/ / DEEPEN '/ / RECONDITION /_/ DESTRUCTION /`T ` <br /> PUMP INSTALLATION / / PUMP REPAIR /4-4--PUMP REPLACEMENT /7 <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 - a <br /> Irrigation, Gravel. Pack DeptlCof Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical � . Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor , t` <br /> Type of Pump. ^ H.P. <br /> PUMP REPLACEMENT tj/State Work Done / a <br /> PUMP .REPAIR: /c�� State Work Done ,� Q llf� � Zo 14P lu4Z5'-� .� <br /> _ _ _ <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 of my- knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN AL INSPECT 0N. TITLE San Joaquin Pump Co. � <br /> SIGNEDZZ <br /> D PD T"PLAN 'ON RE. FRSE SIDE <br /> OR DEPARTMENT USE ONLY Lodi, Caiifarnia 95240 <br /> PHASE I ��� <br /> APPLICATION ACCEPTED BY DATE G � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/,FINAL_INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ,.,. DATE ;/' 4%,7 Y? <br /> E H 1426 Rev. 1-74 3/76 2M <br />