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r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES. 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> %pplication is hereby made to the- San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein describe . This Rulesaand Regulationstofnis the Sane in JoaquinpLocaleHealth with SDistrictan ir <br /> :ounty Ordinance No. 1862 and the <br /> zr <br /> CENSUS TRACT ' - %S <br /> JOB ADDRESS/LOCATION 97 F, t <br /> Owner, s Name Yda er <br /> �' ectr'd Co Phone 369-2845 <br /> City Lodi.. <br /> Address 9707 <br /> - r Inca License # 271 1. <br /> 800 Phone 369-847 <br /> Contractor's Name S^r. Joac�i CQ�aamt. <br /> ds <br /> TYPE OF WORK (Check) : NEW WELL IC/ DEEPEN /� RECONDITION /? DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR I� PUMP REPLACEMENT IrT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 1r <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial XX Cable,-Tool Dia. of Well Excavation 8 <br /> Domestic/private Drilled Dia. of Well Casing <br /> 8 <br /> Driven ti ` Gauge of Casing 12 <br /> .Domestic-/public D p ,, �..�. . <br /> Irrigations": � ��—r -�Gravel..Pack, e th:of Grout�Seal� <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> ' c <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 my kno edge and be ef. <br /> ITLE ` <br /> SIGNED ' <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT US <br /> PHASE I DATE 1'7`c3 �-22- <br /> APPLICATION ACCEPTED BY G� <br /> j ADDITIONAL COMMENTS: r PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE - ' 7 <br /> INSPECTION BY DATE INSPECTION BY , <br /> @� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 1M <br /> E H 1426 <br />