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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OF 0 FICE U E: 1601 E. Hazelton Ave . , Stockton, Calif. <br /> O 1 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) <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 Joaqi <br /> County Ordinance No. 1862 and the Rules and Regulations of: the San Joaquin Local Health Distric <br /> JOB ADDRESS/LOCATION n/p2Tf/ S/D D /�JGrr1,Q QD ggdG oG I¢IA6E�5 61fENSUS TRACT <br /> Owner`s Name �A/i //�c1.e-.0 K L_U G Z- Phone -��Q Ct S' <br /> Address /ALS 96 G dz eOeP c 4e! City e—o dol <br /> Contractor's Name Son Joaquin Pump CO. License �� /��'7 Phone <br /> TYPE OF WORK (Check) : NEW WELL / / , DEEPEN /� RECONDITION /_/ DESTRUCTION /-7PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT /-7 <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 Drivenll� Gauge=of ''Casing <br /> Irrigation Gravel Pack , _Depth of Grout Seal h <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump l�,� -,12 46-- H.P. 2T- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP.REPAIR:....,.._ _- _ /./-..,,:State Work-,.Done <br /> DES-TRUCTION 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 <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 FIN LINSPECTION <br /> SIGNED TITLE San Joaquin Pap Co. <br /> (DXV4 PLOT PLAN ON REVERSE SIDa!�= SnrF[qMPntn St <br /> FOR DEPARTMENT USE ONLY Lodi, Calilarnia 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIOW PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M <br /> E H 1426 Rev. - 1-74 <br />