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-- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFFfCE USE: CJ0 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 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) f3(p �� 0490_ O <br /> .Application is hereby made to the San Joaquin Local Health District for a permit to onstruet <br /> and/or install the work herein described. 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 �%S `�, � G/l� E�6 ia'` ' "" CENSUS TRACT <br /> Owner's Name j/ Phone ,mord- d <br /> Address L City Z.,6,0 / <br /> Contractor's Name <br /> San JOGgUon PE'MP Co.. License #�/C� 7 Phone _ �I <br /> (Division of$a7 caQaon u puar9-240 <br /> a: t <br /> TYPE OF WORK (Check) : NEW WEta°'/�' fihtPjN / ON/ RECONDITI /� DESTRUCTION /-7 <br /> PUMP REPLACEMENT <br /> PUMP INSTALLATION 'S/ PUMP REPAIR /_T <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing f <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 H.P. <br /> Type of Pump <br /> • r <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- knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. 'fan Joaquin Pu p Co. <br /> SIGNED TITLE <br /> wi'n o an pa-u:n hue ur I: <br /> . !��D W PL T PLAN ON RE LRSE SID r44 ...y., . <br /> FOR DEPARTMENT USE ONLY Lodi, Cai:farnia 9,52 0 <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />