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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh'OFFICE USE: Z�1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone:'. (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;7Z,-16 y; <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATEISSUED Date Issued <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 i8 made ,in compliance with San Joaq <br /> County Ordinance ,No. 18b and t ' RuI d Re ul do t e San Joaquin Local Health Distric <br /> JOB ADDRESS/LOCATION S CENSUS TRACT /32-y7o- <br /> Owner's, Name' ►� � ,�.J �.=r:�2&" IC- Phone 2 /36-7 <br /> Address - 3 2 (n3N�12UlCE' <br /> . City' 7`a c1c��,�f <br /> Contractor's Name Son Joaquin Pump Co. <br /> License jg' Phone 364y <br /> IYIS� <br /> ... ...e.,._.- Lada Califo 9740 <br /> TYPE OF WORK (Check): NEW WELL "/ DEEPEN ,/_ RECONDITION DESTRUCTION- <br /> � /-7- <br /> PUMP INSTALLATION L- 7 PUMP REPAIR-/ PUMP REPLACEMENT /-j <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 Ca Ib a 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- 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: /State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth F � � <br /> Describe Material and Procedure <br /> I hereby agree to _comply with all laws and regulations of the San Joaquin LocalHealth 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 putting the..well. in.use.... .The above <br /> information is true to the-best-of my.-knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION <br /> SIGNED . TITLE San Joa uin PUME Co; <br /> DRAW PLOT PLAN ON REVERSE SIDE (Division of San Joaquin Sulphur Ca.) <br /> FOR DEPARTMENT USE ONLY 711 1q. 58cromenro . <br /> PHASE I Lodi, California 95 40 <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT NSPECTIOIN PHASE IV FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />