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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> `FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No rr"L _ _ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued '7-1$- 7y <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 2 Sys S .. ,W�erN S,#VC oO= 4~46 <br /> JOB ADDRESS/LOCATION 7,06TH_ E•vo OF STnGFTc 3 T- T k,�E41. CENSUS TRACT OSC-130 -2-2- <br /> Owner's <br /> 2ZOwner's Name FO N LL.! fa S. y cam+! Phone LU- <br /> -Address 12, 16 o City 40 Q ) <br /> Contractor's Name San Joaquin PUMP Co. License #3/037.8 Phone ��- � <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION /;. - PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY - <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS fj <br /> Industrial Cable Tool Dia. of Well Excavation �^ <br /> Domestic/private Drilled Dia, of Well Casing v1 <br /> Domestic/public Driven Gauge of Casing —4- <br /> Irrigation <br /> 4Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information y <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ,$`_ <br /> rw .Tc� u<•J .0 nr Li <br /> Type of Pump c< H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <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 A FINAL INSPECTION, <br /> SIGNED TITLE bon Joaquin Pum <br /> p Co <br /> W PLOT PLAN ON REVERSE SIDE) (Division of San Joaquin sul hur Co <br /> OR DEPARTMENT USE ONLY IM fl� acramento t. <br /> PHASE I Dodi, Califarnia 9524 <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE,+ Z <br /> E H 1426 Rev. - I-74 2M <br />