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} , 4 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFT;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. • <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED 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 is made in compliance with San Joaquin <br /> County Ordinance/N 1862 and the Rule ons of the San Joaquin Local Health District. <br /> ��! S®eeTM ESQ -toeLeAuUT /4G <br /> JOB ADDRESS/LOCATION p S S ,¢ cr , CENSUS TRACT ' <br /> Owner's Name Phone , T�3 l-�3_S_o <br /> 7/ Aute— /YlO+� o A <br /> Address k- <br /> S �L[Jd► L i� G•��S n! r iC-T� City ' STSG 7cj-,L) <br /> Contractor's Name San Joaquin_Pump Co. License U Phone c9 �7 <br /> ?Division of San Joagai Su]phur_Coj- _ <br /> . ;k _ <br /> TYPE OF WORK (Check) �QL 1� ,� 9 DEEPEN /_7 RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / °PUMPk,REPAIR '/ PUMP REPLACEMENT <br /> Other/ / E <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 4 SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> M 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 <br /> E Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection t. Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor'` '•;,. ; <br /> Type of Pump i H.P. <br /> r <br /> PUMP REPLACEMENT: State Work Done /9"4L 7c%ef3rNC <br /> PUMP-':REPAIR:- <br /> : ,DES4TRUCTION OF WELL: Well Diameter Approximate Depth <br /> ' � Describe Material and Procedural <br /> I hereby agree to comply with all laws and regulationsf of the San Joaquin Local Health District \ <br /> ; end the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> i 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 INSPECTIO-N. San Joaquin Pump Co. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> DEPARTMENT USE ONLY Lodi, California 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE L �1 <br /> ADDITIONAL COMMENTS: <br /> PRASE Il GROUT INSPECTION PHASW XTA AL INSPECTI <br /> ' INSPECTION BY DATE INSPECTION B DATE <br /> �L75 <br /> # E H1426 Rev. 1-74 .. �, . '. _ 2M <br />