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SAN JOAQUIN LOCAL HEALTH DISTRICT 5 <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Cai4&:4I ~ <br /> Telephone:P (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued' /—/,I -7G t <br /> (Complete In Triplicate)Application is 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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 5 (.0 t og_t�e � � <br /> F IrPTT/Pik t1 ce.. r�/aGu� CENSUS TRACT i <br /> Owner's Name —., i <br /> is 7 Phone <br /> Address Z <br /> MT ,e c1 _ U� city S la�, ia�1 <br /> Contractor's Name of Snn San Joaquin Pump Co. � <br /> Jonquin.sluflDhur Ca.) License # Phone I <br /> 36% <br /> -�N. Sacramento-5t. -----�: �7 # <br /> Lodi, Caiifo.rnia 9 ��f } <br /> TYPE OF WORK (Check): NEW WELL /% DEEPEN /_ RECONDITION /_% 'DESTRUCTION /_7 <br /> ALi <br /> PUMP INSTALLATION / / PUMP REPAIR / •/ PUMP REPLACEMENT <br /> Other /% <br />-DISTANCE TO NEAREST: SEPTIC TANKS <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> INTENDED USE TYPE OF WELL CONS <br /> IndustrialTRUCTION SPECIFICATIONS <br /> Domestic/private <br /> stic/private cCable .Tool Dia. of Well Excavation <br /> /pDrilled _.Dia.. of.Well -Casin <br /> Domestic/public Drivg <br /> Driven <br /> Gauge ,of Casing ' <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout z <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump F <br /> H.P. f <br /> i <br /> PUMP REPLACEMENT. ` laklL- 7�uRQi�1G �uM�� �,qP ct'Pll — ,c,sTi��GL <br /> / / State Work Done � c'Jt� / � i <br /> PUMP-REPAIRa <br /> /. /_'Stae`Work"Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth { <br /> i <br /> a <br />[ hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind the State �of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> tfter completion of my work on a new well., I will furnish the San Joaquin Local Health District <br /> TELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />.reformation is true to the best of my knowledge and belief. r <br /> San Joaquin Pump Co. � <br /> IGNED 1 "l`J `� TITLE (Division of Son Joaquin Su€phur Co.) If <br /> (DRAW PLOT PLANON REVERSE SIDE - a <br /> RASE I FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PRASE II FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY <br /> '- DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. p4 <br /> E H 1426 <� 7/72 1M <br /> 4'. t <br />