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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE ORFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 7 7 <br /> (Complete In Triplicate) 027- 4100-is- <br /> Application <br /> 100 C.sApplication 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 /Qd ' S/o c v 7-R't). �&M/ W "VeZ 57ACTO CENSUS TRACT <br /> Owner's Name _ _ r!� _ e,��inA:tJ .__ Phone 36c?- <br /> Address <br /> 6Q-Address //S'(J &,V, lC - 7-7-LE;77 Aj G tj City Z•C),o/ <br /> San Joaquin PumP ILO. . . _._. <br /> Contractor's Name (Myision of San Joaquin Sulphur Co.) License # Zt Phone <br /> T, 711 . ZacrasrMo St. <br /> fOal, uloWflvlu J,.,04.YV - i <br /> TYPE OF WORK (Check) : NEW WELL%/ DEEPEN '/ / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION/ UMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT 'PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <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 ' <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _ a'1,3 �sC3�t1 66 _ <br /> Type of Pump ,u H.P. la <br /> PUMP REPLACEMENT: a/_/ State Work Done ; , <br /> - �_ .. ..may__•-- - ._..- .Y. <br /> PUMP .REPAIR: / / State. Work -Done <br /> DESTRUCTION OF WELL: Well Diameter . Approie mate 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.:iae11 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 TOGR G .AND A FINAL INSPggrIONJ. 4 <br /> SIGNEDTITLE Son Joaquin Pump-CO. <br /> DRAW-PLOT PLAN ON RE LRSE�SIDE) O ivision 0 5a ' oaqu1 u,p urCo „y j !' <br /> - I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �,,. l lad�i, California 95140 <br /> APPLICATION ACCEPTED BY / __ DATE 3-a—' 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I/ INAL INSPECTION { <br /> INSPECTION BY DATE INSPECTION BY ,,- DATE I/-'� <br /> 4 <br /> E H 1426 Rev. 1-74 3/76 2M <br />