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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FAR OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 A( <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 72. <br /> � 4 <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 o. 1.862 and the amt egulations of the San Joaquin Local Health District. i <br /> JOB ADDRESS/LOCATION <br /> SG /�- 1/�.2� CENSUS TRACT <br /> Owner's Name C 12-d�- e- 0 Phone <br /> Addressr,? I %lir Csy��I .S' T <br /> City <br /> Contractor's Name San Joaquin Pump Co. <br /> License # "`�Q Phone -.f7/ <br /> ivMon of San joaquin . <br /> TYPE OF WORK (Check) : NEW DEEPEN / / RECONDITION / (✓ ,DESTRUCTION /7 ; <br /> PUMP INSTALLATION / / PUMP REPAIR k� UMP REPLACEMENT /7 <br /> Other, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE.DISPOSAL FIELD CESSPOOL/SEEPAGE' PIT. OTHER p <br /> E <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL t <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <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 M <br /> Disposal- Other Other Information 9 <br /> Geophysical ' - Surface Seal Installed By,.--- <br /> PUMP INSTALLATION: Contractor <br /> - -- <br /> Type-of -Pump r � H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: P-/--state Work Done a <br /> DESTRUCTION 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 INSPECTION. $an Joaquin Pump Co. <br /> SIGNED TITLE ; <br /> D PLT PLAN 'ON REVERSE SIDE , <br /> PHASE I F90R DEPARTMENT USE ONLY Lod Co k fq,rnic 95240 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION . f <br /> INSPECTION BY DATE INSPECTION BY DATE 7Q <br /> E H 1426 %Rev. 1x-74 „., 3/76 2M <br />