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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP O'FF`ICE iTSE: 1601 E. Hazelton Ave. , Stockton, Calif. / 1 <br /> Telephone : (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. } <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued�2--/127 <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 No. 1862 andithe Rules and Regulations of the San Joaquin Local Health District. } <br /> 1 � ENSUS TRACT # <br /> JOB ADDRESS/LOCATION /VveTf/ <br /> Owner's Name <br /> Phone 33`f-� f Z L r <br /> 7.2-57 E City 4 11:2 <br /> Address ` <br /> t9ivision of San.laagpin.Sulphur Cal) License �� � /(J PllOne <br /> Contractor's Name gnto St_ <br /> �ndi �sslif -nia 9 '24 ; <br /> TYPE OF WORK (Check) : NEW WELL /�/ DEEPEN /�/ RECONDITION / / DESTRUCTION / T <br /> PUMP INSTALLATION _/_/ PUMP REPAIR /&. ,PUMP REPLACEMENT <br /> Other <br /> ;I I <br /> DISTANCE TO NEAREST: SEPTIC' TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER" PROPERTY LINE. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> ~ Industrial 1 Cable Toa] of Well. Excavation � <br /> Domestic/private 1 Drilled Dia.; of Well Casing <br /> Domestic/public ? Driven Gauge of Casing <br /> Irrigation ,tet , _ Gravel Pack Depth of Grout Seal, all <br /> Type of Grout <br /> Cathodic Protection Rotary <br /> ,. <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump ' <br /> I <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR:.. /4.�?ta e_Woxk-Donees _ �S. �C.—: .. I�Av_jo_ <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter PP P <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 A FINAL NSP Sorg Joaquin Pump CC, <br /> TITLE <br /> SIGNED , <br /> (D W PLOT PLAN ON REVERSE SIDE) .rye <br /> FOR DEPARTMENT USE ONLY Lodi, Califorr o 95p `. <br /> PHASE Imo ' <br /> APPLICATION ACCEPTED BY DATE <br /> ��_r� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE I I/FINAL INSPECTION <br /> DA f <br /> Y <br /> INSPECTION BY DATE --INSPECTION B <br /> 0,177 _ . 2M � <br /> P IA?A pa«_ . 1-74 <br />