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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE' OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuea <br /> (Complete In Triplicate) <br /> oaquin Local Health District fora p <br /> Application is hereby made to the San Jermit to construct <br /> This application is made incompliance with San Joaquin <br /> and/or install the work herein described. <br /> I County Ordinance No. 1862 and the 'Rules and Regulations of the San Joaquin Local Health District. <br /> t <br /> JOB ADDRESS/LOCATION /I7 P <br /> S �, IM LCIS �CI 1n• S6u � t f CENSUS TRACT <br /> Owner's Name /07Phone - 2- 2S <br /> Address '2- /JCity <br /> San Joaquin PUMP CO• License ���/Q 7 Phone3 <br /> Contractor's Name in Sut hur Co.) <br /> acramento St. <br /> Lod4.001I{0rn1a <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / DESTRUCTION / <br /> PUMP INSTLATION / PUMP 'REPAIR UMP REPLACEMENT / ` <br /> AL <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERPLIC DOSTIC WELL <br /> 4 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL CONSTRUCTION SPiE�CIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> k Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/Private Drilled Dia. of Well Casing <br /> -Domestic/public Driven Gauge of Casing <br /> Irrigation . <br /> Gravel Pack Depth of Grout Seal <br /> TYPe of-Grout�-�-.--. . _. <br /> Cathod ' �RotaricProte-c-tton:W Y Other. Information <br /> _Disposal Other <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _ H.P. <br /> Types of Pump _ <br /> PUMP REPLACEMENT: / / il State Work Done ,» <br /> i PUMP .REPAIR: / T State Work Done kesul - T <br /> DESTRUCTION OF WELL: Well Diameter Approximate DepthF— - <br /> Describe Material and Procedure <br /> y 1 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 <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 GRO AND A FINAL INSPECT N. San loaquin uMp o• <br /> I SIGNED r TITLE (Division of San Joaquin Sulphur Co.) <br /> DRAW f'T T' PLAN ON RE FRSE. SIDE) <br /> 7]1 ;N.' acro ento, t. j <br /> FOR DEPARTMENT USE ONLY Lod%, a I ornia 7 <br /> G PHASE I L DATE <br /> j APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS: I11 FINALMATEE <br /> CTION <br /> INSPECTION BY :. DATE INSPECTION BY <br /> 3/76 2M <br /> LIu 1--74 <br />