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FSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR!'OFFICE USE: 1601 E. Hazelton Ave. , Stockton; Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7s:2Z, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued `/�j <br /> f (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 /> �E County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ' JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner°s Name 3 EC iv y E vS Phone <br /> t <br /> Address S C1 G I-IT 1)2 It city c-k_jc),rl <br /> as oaquin Purnp Co. <br /> Contractor's Name IDirision of San Joaquin Sulphar Cal License # Phone <br /> £ t OfiIAR: <br /> TYPE OF WORK (Check): NEW WELL/? DEEP '/-7 RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION X1 PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other E7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSALjFIELD .. CESSPOOL/SEEPAGE PIT OTHER -� <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL c� <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 O <br /> Irrigation Gravel Pack Depth; of Grout Seal <br /> Cathodic. Protection Rotary Type of Grout <br /> Disposal f Other Other Information <br /> Geophysical s San Joaquin �p CfSurface Seal. Installed By: <br /> Mylsion of San Joaquin Sulphur CO.i <br /> i PUMP INSTALLATION: Contractor 500 E. Kettlemnn <br /> Type of Pump Lodi7 j -S H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> i <br />—PM I.REPAIR: /:� State Work Done ' <br /> ES RUCTION 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 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 CALL FOR-A'GROUT INSPECTION <br /> PRIOR TO GROUTING, AND A FINAL INSPECTION. I <br /> SIGNED lr�� �/ TITLE <br /> w (DRAW PLOT PLAN ON REVERSE <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I <br /> APPLICATION ACCEPTED BY ( 1 _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I ROUT INSPECTIONP / "NAL NSPECTIJDN <br /> INSPECTION BY A11A DATE INSPECTION TE . <br /> E H 1426 Rev. 1-74 <br />