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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE:OFFICE USE: Z�1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone:. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7b_6 4; <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 7 <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 Joaq <br /> County Ordinance No. 186 and t4e Rul d Regu1 do " tie San Joaquin Local Health Distric <br /> zz:03 E_'ci-tE,�oK_ �YJ/�e /�/ C�t�U;PP <br /> JOB ADDRESS/LOCATION S " CENSUS TRACT /32-rU7o- <br /> Owner's Name _ /�.� S A� IL Phone K2 - /3 (67 <br /> Address 3 2 6 3 NtF/20Ice( ( - City' S Td cKld-z/ <br /> Contractor's Name San Joaquin Pump Co. License /f ?ib-37$ Phone 3 - / <br /> M <br /> h Caoca+� 9, <br /> TYPE OF WORK (Check) : NELoW cWELLlif/ / 9,DEEPEN /7 RECONDITION DESTRUCTION /-T- <br /> PUMP INSTALLATION) / / PUMP REPAIR/ PUMP REPLACEMENT r7 <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 S <br /> Domestic/private Drilled - Dia:l 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 A.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: /"rState 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 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 AND A FINAL INSPECTION <br /> SIGNED TITLE San Toa uin Pum Co: <br /> -� DRAW PLOT PLAN ON REVERSE SIDE) ( oa of Saa loaqu n Sulphur Cc) <br /> FOR DEPARTMENT USE ONLY ill IT Socromenro <br /> PHASE I Lodi, Califarnia 95 40 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE / <br />