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• SA.*I JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6181 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-231 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6—A.9—V <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 aescribed. 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 T'.fyj9C�r A ryS ,D ojJn BRn-,OT IeO CENSUS TRACT <br /> Owner's Name Z6 / ){11�s Phone <br /> Address /Z 3 p Jr. FA�Gmc�/i V a City LOO/ t <br /> Contractor's Name �� �,,gQ►�„� paw p (� License :f / Phone 9 <br /> TYPE OF WORK (Check): NEW WELLL-7 DEEPEN /-T RECONDITION /_� DESTRUCTIONL-7 , I <br /> PUMP INSTALLATION L�PUMP REPAIR L-7 PUMP REPLACEMENT J <br /> Other L/ <br /> DISTANCE TO NEAREST: SEPTIC TANK ~SEWER LINES PIT PRIVY P <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 n <br /> Domestic/private Drilled Dia. of Well Caning <br /> Domestic/public Drivjn Gauge of Casing <br /> Irrigation Gravel Pack Pcpth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: ContractorSg,� cTd,w 0&e') 92 d� <br /> Type of Pump age'd'47G4S.,If �,- H.P. 7 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPREPAIR: L-7 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 in true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN FI AL INS <br /> SIGNED TITLESAIU <br /> QIHN PUMP �OMPAWI <br /> DE r <br /> W PLOT PLAN ON REVERSE SIocn <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 2 <br /> P. 0. Box 201 � <br /> � ,�— <br /> APPLICATION ACCEPTED BY��d /����/'�a �/,� Lodi, "*0 95240 <br /> ADDITIONAL COMMENTS: f <br /> PHASE II GROUT INSPECTION PHASZ III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DAT `' <br /> _.� <br /> 2M <br /> E H_1426 Rev. <br />