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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. . 7� 13� <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 1 2 7- d <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin T.ocal 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. 1862andtL'}L,)eIRules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION /tai W/o� ,, SOcr7'� rWo oj.�i6'��ENSUS TRACT <br /> 1 <br /> Owner's Name Phone 3 _J - <br /> City (��38 <br /> Address �{ 3 ,- S. ;.�TT L 0 <br /> I <br /> Contractor's Name Son loaarsast Pump Co. License <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION DESTRUCTION / T <br /> PUMP INSTALLATION / / PUMA. REPAIR / PUMP REPLACEMENT /77 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER 1 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL .— PUBLIC DOMES'T'IC 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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal _ Other Other Information <br /> Geophysical- Surface Seal'Instal.led By: <br /> PUMP INSTALLATION: Contractor <br /> Type. of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> k PUMP :REPAIR: / State Work Done : Id. �14 P (ux-,Q/sJr 7e <br /> i <br /> i 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, thewell. 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_Z ,. , INSPECTION ! TITLE Sail loaquill Pump Co. <br /> SIGNED <br /> _ DRAW PLOT AN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY Lodi, California 95240 <br /> SE I <br /> LICATION ACCEPTED BY d3 / DATE <br /> ADDITIONAL COMMENTS: -� <br /> PHASE II GROUT INSPECTION PHASE II /FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE <br /> ` o 2M <br />