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I <br /> I <br />{ <br /> FILE COPS' <br /> AN JOAQUIN LOCAL HEALT:' _ `STRICT <br /> 1-01 FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z7-,P /o <br /> /THIS PERMIT EXPIRES 1 VEER FROM DATE ISSUED Date Issued <br /> (Complete Itt Triplicate) <br />-lication is hereby made to the San Joaquin Local Health District for a permit to construct <br />./or install the work herein described. This application is made in compliance with San Joaquin f <br />.nty Ordinance No. 1862 and the Rules and Regulations of the San,Joaquin Local Health District. <br /> ADDRESS/LOCATION E i ' <br /> P Q/ rI CENSUS BRACT <br /> er's Name e^ <br /> Phone <br /> ress , _ , A <br /> City G !.7 b <br /> tractor's Name Sa.n loaquil PUMP Co. <br /> •• t••rr rt 7aQ <br /> License # �'Phone, y?1 a ; <br /> E OF WORK (Check): NEW�£tELL ] ` DEEPEN /_y RECONDITION`] - DESTRUCTION'/_7 <br /> PUMP IAIaTALLA'f ION /? PUMP REPAIR / PUMP REPLACEI4ENT <br /> Other <br /> I'ANCE TO NEAREST: SEPTIC TANK SEWER LINES 7 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESS 0/SEEPAGE PIT OTHER <br /> PROPERTY LINE .. PRIVATE DOMESTIC WELL'— PUBLIC DOMESTIC. WELL <br /> INTENDED USETYPE nF WELL CONSTRUCTION SPECIFICATIONS <br />_ Industrial Cable Tool Dia. of Well. Excavation a' . <br />_ Domestic/private Drilled Dia. of Well Casing <br />— Domestic/public Driven Gauge of Casingx <br />_ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout �$ <br />_Disposal Other Other Information _ <br /> Geophysical ---��,� "•;` <br /> Surface Seal Ins al ed By: d <br /> INSTALLATION: Contractor ' <br /> Type of Pump <br /> H.P. <br /> (� <br /> REPLACEMENT. State Work Done <br /> .REPAIR: d rr /�� 'Tr1.CBi�Na• ' <br />- /�State Work Done <br /> { I <br /> RUCTION OF WEN.L: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> reby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> the State of California pertaining to or regulating well'construction. Within FIFTEEN DAYS <br /> r completion of my work on a new well, I will furnish the San Joaquin Local Health District a ` <br /> DRILLERS REPORT of the well and notify them before putting thes.well in use. The above <br /> rmation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> t TO GROU D A FINAL INSPECTIO , <br /> ED a TITLE San Joaquin rump Co. <br /> DRAW p P ON RP.��RSE SIDE h ,= <br /> I FOR DEPARTMENT USE ONLY ' <br /> Lodi, Celi{oraio 95240 <br /> CCATION ACCEPTED BYTAX <br /> DATE -,72— � <br />