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_ SAN JOAQUIN LOCAL HEALTH DISTRICT 3 <br /> FOR,1OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��-•59•L� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -Z7 <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 /> CountyiOrdinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> W"I OP -t L elt S/4c&4,m4e,,4o �+6"j j fle57 !�lJ <br /> JOB ADDRESS/LOCATION 4.70ar! Sfoe a „/�,,,� CENSUS TRACT <br /> Owner's Name A :u OF Phone _� �l.r.�— Z 72 <br /> Address4 14 7, _� rT/t>.0 _ --... City /qcAmpa <br /> Contractor's Name 5nn Joagu'sn Pump Co., License #r` Phone �j-��-71 <br /> TYPE OF: WORK (Check): NEW WELL / DEEPEN /_/ RECONDITION /—/ DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT f{�/ <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing �f <br /> Domestic/public Driven Gauge of Casing . <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /CState Work Done gk �.Le .Y2 4-k + y2 N P s�l�lsy�f s <br /> PUMP REPAIR: / J State Work Done <br /> „RESTRUCTION 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. <br /> Son Joaquin Pump Co. <br /> SIGNED TITLE %vls;on of San Joaquin Sulphur Ca.) <br /> (DRAW PLOT PLAN ON REVERSE SIDE q. Sacramento �t. <br /> DEPARTMENT USE ONLY <br /> PHASE I : <br /> APPLICATION ACCEPTED BY DATE ?f 20"�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL,,FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />