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FAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 160�s. Hazelton Ave. , Stockton, Ca:�. / <br /> Telephone: (209) 466-6781 '� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssudXC 22 1971 <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATN _�/d ���T��s ,�15 �L> CENSUS TRACT <br /> IO <br /> Owner's Name Gou/ /)S.A?i 7.E'/ Phone 2,/j 5?-,?e,77____ <br /> Address ��Q� 6 f�( �pnn City Z0401 <br /> Contractor's Name San Jo^.ru;n Pimp Co. LicenseI/��Z�Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_7 RECONDITION /_7 DESTRUCTION /^T <br /> PUMP INSTALLATION / / PUMP REPAIR 1�:4 TMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY C <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Q <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 i <br /> Domestic/public Driven Gauge of Casing C <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 /> i <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 <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 k owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU AND A FNA San Joaqu4n rump Co. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY Lodi, Colifunia 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION ' PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY fly DATE a ti <br /> 2M <br />