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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR ,OFFICE USE: V� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued' 7-E7-76 <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 Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �� f U�i�,S -- CENSUS TRACT <br /> I <br /> Owner's Name /a L, �3�'0S -- -- - Phone y~ 2 <br /> Address �, city <br /> Contractor's Name San haquin Pump Co. License # Phone <br /> Hl division of, on Joaquin Sulphur Co.) <br /> i <br /> TYPE OF WORK (Check) : NEW1*LLali :o M,PEN /`7 RECONDITION / DESTRUCTION /� <br /> 'PUMP INSTALLATION / / PUMP REPAIR /�LP- PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> X <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/publics Driven _Gauge of Casing; <br /> Irrigation Gravel Pack 4\ Depth`.of Grout Seal <br /> Other r- <Rotary._ h ___Type of--Grout-- <br /> Other <br /> f_-Grout-Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /6..e State Work Done A14 D C"cy Cg_,ll.c.J 7_o Cct e- <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`vweli', I will furni'sh� tti'e San Joaui <br /> qn .Local Health District a <br /> WELL DRILLERS REPORT-A the wm b <br /> ell and notify- theefore putting the well in use. The above <br /> information is true to' the best of my knowledge and belief. <br /> - San Joaquin Pump Co. <br /> SIGNED TITLE (Division of Soo Igetqy4pc _ <br /> Z (DRAW PLOT PLAN ON REVERSE .SIDE) 711 N. Sccrarrentp re <br /> FOR DEPARTMENT USE ONLY G'Ji, Colifnrnia 9524o <br /> PHASE I <br /> APPLICATION ACCEPTED BY Q/ DATE <br /> ADDITIONAL COMMENTS: .IN" <br /> PHASE II GROUT INSPECTION PHASE iI F NAL INSPECTION <br /> INSPECTION BY 11. DATE INSPECTION BY DATE Z-2,0 ^76 <br /> 10 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426. 1 - 7/72 IM <br />