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r <br /> 9-0 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FA OFFICE USE: 1/ 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 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: 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION h m r IQ U_),es I j 4 _,It/'JC <br /> SUS TRACT <br /> Owner's Name Phone74 — VVY- <br /> Address J�.SZS _A)• lCt,CV6-- City 66,01 <br /> San Joaquin Rump Co. ` <br /> Contractor's Name (WASi4n of San Joaquin SILIohar ca-)_ _ License #3 37�' Phone <br /> 711 N. Sacramento "zt. - t <br /> Lodi, Califer n'a 9Z' _ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION /_/ ° DESTRUCTION <br /> PUMP INSTALLATION /V 'PUMP REPAIR / / 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 Excavatio <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal Gl ! <br /> Cathodic Protection R6tary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP--INSTALLATION: Contractor -5,4,0 3 -4 Lt I j A, <br /> Type of Pump _ ��p,e,Q�,C, - - H.P. Q <br /> PUMP REPLACEMENT: / / State Work Done <br /> I <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 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 GROUT D A FINAL INSPECT <br /> SIGNED ` TITLE S sOaquin Pli <br /> mp Co. <br /> DRAW PLUT PLAN-ON REVERSE SIDE ivcsion of San!Joaquin SuEphur'ca,) <br /> FOR DEPARTMENT USE ONLY ate" ' ,�r• <br /> PHASE I Lodi, CGliforn�a ;3�2 <br /> APPLICATION ACCEPTED BY / _ -- _ — DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYog&eDATE ly- <br /> 3/76 2M <br /> T <br /> E H 1426 Rev. 1-74 <br />