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` J k <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR O'FF'ICE 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 1 YEAR FROM DATE ISSUED Date Issued l }-76 <br /> (Complete In Triplicate) ; <br /> Application is'hereby wade 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. 1662 and%the Rules and Regulations of the San Joaquin Local Health District. <br /> ` <br /> A S r 6 ; PCTiev L�.VF (/ar-TW 9'1vE o f CENSUS TRACT <br /> JOB ADDRESS/LOCATIONIK� &—;n ra.✓ AJ r �T 'S/os r2uj: sNc'U __ <br /> Owner's Name C-0Phone 6Q- L_ 73V <br /> Address t iG A�tl .4/ City <br /> Son Joaquin Pump CO. <br /> Contractors Name rp <br /> License $ Phone g 7� <br /> Lodi, CoiifornMJ95240 : <br /> TYPE~6F-W­0U (Check): NEW WELL / ! _DE$PEN-/7 RECONDITION 'y-7. DESTRUCTION /? <br /> PUMP INSTALLATION jg . PUMP REPAIR /� <br /> ALPUMP REPLACEMENT w <br /> Other ! f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD '; CESSPOOL/SEEPAGE PIT OTHER <br /> Qf <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool 0' Dia. of Well Excavation • N, ; <br /> k <br /> Domestic/private' Drilled Dia. of Well, Casing _ <br /> Domestic% ublic_.. Ariven _ __.. auge._of_Ca ung__ t• - __ <br /> Irrigation l Gravel Pack Depth of Grout Seal <br /> Other Rotary Type .of Grout <br /> Other Other Information <br /> 1 <br /> ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump -__ <br /> H.P. <br /> k PUMP REPLACEMENT: - <br /> / State Work DOne.t Z,9J_c_e Poly O W� 6, 1_ U E SAIIh� rQZG <br /> PUMP REPAIR: /_7 State Work Done [ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material. and Procedure <br /> k 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. Son Joaquin Pump Co. <br /> (Division of Son Joaquin Sulphur Cos <br /> ' SIGNED TITLE 711 N Sarcermanta St <br /> (DRAW PLOT PLAN ON REVERSESIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1, <br /> APPLICATION ACCEPTED BY �f DATE 6 7� <br /> ADDITIONAL COMMENTS: t <br /> PHASE II GROUT ;INSPECTION PHASE 111191INAL INSPECTION <br /> INSPECTION BY 'DATE INSPECTION BY DATE <br /> 4r <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />