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r <br /> F'OR OFFICE •USE• SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' Telephone: (209) 466-6781 <br /> 3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) <br /> Date Issued 3 76 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> f and/or install the work herein described. This application is made in compliance with San Joa quiCounty Ordinance No. 1862 and th Joaquin Local Health District.q Rules and Regulations of the San Jin <br /> ct. <br /> JOB ADDRESS/LOCATIONC <br /> CENSUS TRACT <br /> Owner's Name L <br /> Phone <br /> Address � ��- <br /> !a r ���� L� <br /> City zo eql <br /> 4 Contractor's Name ' rj <br /> -� License ! 2%L:j? 361-9V71 <br /> TYPE OF WORK (Check) NEW NEW WELL /_7DEEPEN / / RECONDITION 1-7 DESTRUCTION /7 <br /> _ <br /> PUMP INSTALLATION; <br /> /_/ <br /> PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWERyLINES <br /> SEWAGE. DISPOSAL FIELD PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER j <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS : <br /> Cable Tool Dia. of Well Excavation <br /> _ Domestic/private Drilled <br /> Dia. of' Well Casing { <br /> - Domes tic/public - � .-�' . - -�=•Driven- `"._ - _. _.. _ x <br /> Irrigation ' Gauge`of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: /State Work Done <br />-PUMP_.REPAIR-.-_ State Work Done a <br /> ESTRUCTION OF WELL: Well Diameter <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 is true to the best of my knowledge and belief. <br /> SIGNED `�~ Saai Joaquin Pump Co. <br /> TITLE (Division of San Joaquin Sulphur Co.) i <br /> (DR�RLL�ANONOT PREVERSE SIDE au:.eursrcl� �r. <br /> PHASE I �09 -A 4 Y Low ,N.S�e�e7i FOR DEPARTMENT USE ONLY ! <br /> APPLICATION ACCEPTED BY <br /> UDDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE II F �ALNSPECTI N[NSPECTION BY DATE INSPECTION BYATE d <br /> CALF, FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 1M <br />