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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FG, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a�p <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 J .3 J'J . ,[� ,$._,. CENSUS TRACT I <br /> Owner's Name` (LIe•t7 CD2 Phone <br /> -Qom/ <br /> Address Cit G a <br /> Contractor's Name Son Joaquin Pump Co. � <br /> License 4t Phone <br /> ' iY15177i - + <br /> kj <br /> 40 <br /> TYPE OF WORK (Check): NEWS WELL r/ ZDEEPEN _ <br /> _/ / RECONDITION' /_7 DESTRUCTION -/ <br /> PUMP INSTALLATION / / PUMP REPAIR /% PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK , SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER � { <br /> f" 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. of Well Excavation <br /> Domestic/private t Drilled Dia. of Well Casing . <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation k Gravel Pack Depth of Grout Seal <br /> :Other I Rotary 'Type of Grout _ <br /> 1 Other k Other Information <br /> PUMP INSTALLATION: Contractor �l <br /> Type .of.IPump H.P. i <br /> PUMP REPLACEMENT: Ar- <br /> S tate Work Done el <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION 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 i <br /> information is true to the best of my\knowledge and belief. <br /> San kanuin Pump to. <br /> SIGNED - �J TITLE <br /> (Division of San Joaquin 5uiphur Co.) <br /> DRAW PLOT PLAN ON REVERSE SIDE 711 N. Sacramento St. <br /> FOR DEPARTMENT USE ONLY Loai, alp ornia O/ . <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ ._,_,_.,,.,---•._.. DATE I-2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS � I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /�•�� . <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. C� <br /> E H 1426 7/72 I <br />