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SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> F0R OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. R <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ]7-1D3e)P <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 Joaquin <br /> County Ordina ce No. .l <br /> If the Rules and Regulations of the San Joaquin Local Health District. <br /> .IOB'AADDDRESS/LOCATIO CENSUS TRACT <br /> ge-2 /SCJ 54 <br /> Owner's Name g Phone 3&9 --ZZ <br /> Address /G,3,9 Ai A cf?- City 5' <br /> San Joaquin Pump CO. <br /> License # 7j632R Phone 6y�5F7/ <br /> Contractor s Name ut hur ca <br /> 11 N. Sacramento St. IL <br /> Lodi, California 95ZgU <br /> TYPE OF WORK (Check) : NEW WELL/ 7 DEEPEN / / RECONDITION /� DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT I� <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 Driven Gauge of Casing q� <br /> Irrigation Gravel Pack Depth of Grout Seal \' <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 n H.P. <br /> PUMP REPLACEMENT: /State Work Done 41- /1i 7X_ <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 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 AND A FINAL I SPE ON. r <br /> TITLE San Joaquin Pump Co. <br /> SIGNED <br /> DRAW PLOT T PL ON REVERSE STD ° ° paqu n SURE? C�,) <br /> OR DEPARTMENT USE ONLY Lodi Caiifarnia 9724 <br /> PHASE I <br /> APPLICATION ACCEPTED BY f DATE 1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTWN PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M <br /> E H 1426 Rev. 1-74 <br /> 3/76 <br />