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. cB .. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO>� OFFI E USE: 1601 E. Hazelton Ave. , Stockton, Calif. ` <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 IssuedG <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District'. - <br /> 5")e6 PA; <br />' JOB ADDRESS/LOCATION 7' lJ�u`S <br /> G `� Pte° `' � n CENSUS TRACT Dom-- <br /> Owner's Name 11 A_� <br /> Phone6 <br /> Address �{v/ LtJ e ..lu e,UE •R L) <br /> San Joaquin Frump CUF City _C.o 0 l <br /> Contractor's Name Division of Son Joaquin Sulphur Co.) �T� µ/ <br /> License # <br /> 711 N. Sacra�o�e�ro - — Phone <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /? RECONDITION /? DESTRUCTION 1-7T <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /_7Other % <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL . <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> ! Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia, of Well Casing ; <br /> Domestic/public i Driven Gauge of Casing l <br /> _ Irrigation I Gravel Pack Depth of Grout Seal <br /> Other '-� <br /> - .� 1 Rotary Type of Grout xa <br /> Other Other Information ~ <br /> I ---� prof, <br /> PUMP INSTALLATION: ; <br /> Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: /_7 State Worts Done <br /> PUMP - { <br /> REPAIR: .�S.tate-Work Done. J +_ y_ l /�." G/.� /•rdGy/-�//a! <br /> j <br /> ESTRUCTION OF WELL: <br /> 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 bestgof my knowledge and belief. <br /> SIGNED r - `r4 r Sar: Joaquin Putnp Co. <br /> 1 (Division of San Joaquin Sulphur Co.) <br /> TITLE M c n' <br /> 1 (DRAW PLOT PLAN ON REVERSE SIDE 24 <br /> PHASE I FOR DEPARTMENT USE ONLY e <br /> f <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: - ."' .._ <br /> '` <br /> PHASE II <br /> GR NSPECTION PHA E II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL F'OR.A GROUT INSPECTION PRIOR TO GROUPING AND FINAL INSPECTION. <br /> E H 1426 7/ M <br /> k <br />