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( j SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 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 1 YEAR FROM DATE ISSUED Date` Issued 6 <br /> (Complete In Triplicate) 11' <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 Ordnance No. 1862 and the Rules and Regulations of the San Joaquin Local., Health District. <br /> JOB ADDRESS/LOCATION0.4 W 0 Dustin O Jahant Rd. CENSUS TRACT <br /> Owner's Name JERRY KUYER <br /> Phone <br /> Address 557d <br /> City Lodi <br /> Contractor's Name G p & IRRIGATION INC. License # 309O3lPhone 727-5548 <br /> ,1 <br /> TYPE OF WORK. (-Check) :_ANEW WELL,/_.—DEEPENCOND.T_TION�I? DESTRUCTION__ <br /> PUMP INSTALLATION I I PUMP REPAIR PUMP REPLACEMENT/-7 <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER INES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> INTENDED USE TYPE OF WELL <br /> IndCONSTRUCTION SPECIFICATIONS <br /> _- , ustrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other - _ Rotary Type of Grout <br /> Other Other Information <br /> i <br /> PUMP INSTALLATION. <br /> Contractor me A Above <br /> Type of Pump H;P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /X/ State Work Done <br /> Dei ta . to 40HP with, Johnston <br /> DESTRUCTION OF WELL: - Well:Diameter components, added 30, <br /> Describe Material and Procedure Approximate Depth <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 rue to the best of my knowledge and belief. <br /> SIGNED <br /> TITLE u <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> DATES 77 <br /> PHASE II GROUT INSPECTION / <br /> LNSPECTION BY PHASE I.II(FINAL INSPECTION <br /> DATE INSPECTION BYDATE �/ -77 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 Im <br />