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03 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F(1Fs.OFFICE USE: u- 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERRMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> JOB ADDRESS/LOCATION ---- S (5' & V�� t <br /> CENSUS TRACT <br /> Owner's Name - 7-.L <br /> Phone 36C <br /> Address 146 9 /1G <br /> City /_6 ,0/ <br /> Contractor's Name Sari :1oa--u°rte Pump co, <br /> License <br /> (Division of San Joaquin Sulphur Ce,j `3- 7 Phone ]� <br /> TYPE OF WORK (Check) :"� WEtr . DEEPEN /_7 RECONDITION /-7 DESTRUCTION I7 <br /> PUMP INSTALLATION /L�jUMp REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTYC TANK SEWER LINES <br /> SEWAGE DISPOSAL FIELD PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> TENDED USE <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTYP$ OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Domestic/private Drilled \ <br /> � Cable Tool Dia. of Well Excavation <br /> Dia. o€ Well Casing <br /> Domestic/public _ Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal t <br /> Cathodic Protection _�� Rotary <br /> y Type of Grout <br /> Geophysical <br /> Other Other Information <br /> ---�---- <br /> Surface Seal Installed B • <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump me:-2.c �z <br /> - - H.P. �2 � <br /> PUMP REPLACEMENT: Ll State Work Done V <br /> PUMP 'REPAIR: /_7 State Work Done <br /> a <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth I <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, <br /> SIGNED <br /> TITLE San Joaquin PuMp Ci. <br /> 11fKAW PLOT PLAN ON REVERSE SIDE (DiyisiCn O an oaqu n u p <br /> PHASE T 'u y FOR DEPARTMENT USE ONLY <br /> APP TL CATION ACCEPTED BY �Qt i, C . orwo 9 240 <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE IT GROUT INSPECT N HAE T�ON, <br /> INSPECTION BY DATE PSE III FINAL 1NSP <br /> INSPECTION By 4 <br /> DATE a <br /> E H 1426 Rev. 1-74 <br /> t,/7 c� sur <br />