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.� SAN JOAQUIN LOCAL HEAL"•H DISTRICT <br /> FOh OFFLCF. 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 YnAR FROM DATE ISSUED Date Issued Q-w-"e. <br /> (Complete In Triplicate) <br /> Application is hereby mado to the San Joaquin Local 11calth District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with Ban Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION — S G c.LC Sb CENSUS TRACT <br /> Owner's Name 1221CC% F /,/ ,5:k-F 7-7— Phone 7s9 -3946 / <br /> Address ! 7 2 COC) t L f iz L/'i Y' 2 /� City ( O a l <br /> Contractor's Name Son Joaquin Pump Co. License d ,3&37 Phone 9- ; 7/ <br /> D'n•;on o1 S., J:a Vvin S.101"C°' <br /> TYPE OF WORK (Check): NEVV6' '1rF ZiiAPEN /7 RECONDITIONjg RECONDITIONDESTRUCTION /7 <br /> PUMP INSTALLATION L/ PUMP REPAIR /_ PUMP REPLACEMENT I <br /> Other L/ <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 A� <br /> Industrial Cable Tool Dia. of Well Excavation 4 <br /> Domestic/private Drilled Dia. of Well Casing d <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type o_ Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. - <br /> PUMP REPLACEMENT: / / State Work Done f J <br /> PUMP REPAIR: L�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 regula.ionn of the San Joaquin Local Health District <br /> and the State of California pertaining to or reguls:ing well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnich 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 beet of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSP N. <br /> SIGNED =7.. TITLE S^n Joaquin Pump (.o. <br /> DRAW PLOT PLAN 09 REVERSE SIDE Z "'" <br /> FOR DEPARTMENT USE ONLY ����I�fie� <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE DATE �P- i- 7C <br /> ADDITIONAL COMMENTS: +7/ <br /> PHASE II GROUT INSPECTIONPHASE II:TINAL INSPECTI N <br /> INSPECTION BY DATE N, INSPECTION By 0 <br /> E J1 1426 Rev. 1-74 h/75 PM <br />