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OAQ TRICT <br /> FOA(OFFICE USE- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> IN LOCA �HET�DIS' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> T11IS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (-ftr-� � ., (Complete In Triplicate) pg /40- 1`7 <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 /> 'B,&w,e,P.eJ Wgrerz.C,eo ct 8 m. k_ Rd .sou7,-0 <br /> JOB ADDRESS/LOCATION 6F g o ve 2 ,- Cis T Sip 4F Ar e a i T S A�d CENSUS TRACT <br /> Owner's Name jZ here-r zoow'. Phone 93/1--23q-1 <br /> Address AWWL SkCity S70-ak_cj.1 <br /> Contractor's Name .�c1� �q c u j License # Phone W6 Py7/ <br /> TYPE OF WORK (Check) : NEW WELL/—/ DEEPEN /7 RECONDITION /'7 DESTRUCTION /-7 <br /> PUMP INSTALLATION KI PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /_7 �? <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �• <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC-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 CL <br /> Geophysical Surface Seal-Installed By: <br /> PUMP INSTALLATION: Contractor A.o Z-v a u r -d P"-iu . <br /> Type of Pump .4 o- 5 ue e- H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP.REPAIR: /? State Work Done <br /> t <br /> ES•TRUCTION 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$ q t District <br /> and the State of <br /> 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. I WILL LA&L OR A.G OUT RSPECTION <br /> PRIOR TO GROUTING AND A FIN INSPECTION. <br /> SIGNED TITLE on of Son Joaquin Sulphur Co,) <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 2 �S <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE 1JUPINAL SPECTION <br /> INSPECTION BY DATE INSPECTION BY/ TE � <br /> ! E H 1426 Rev. 1-74 1-74 2M <br />