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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> w <br /> FOL QFFICEaUSE: fcp 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 ` <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No��7-zz&le" <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued(T�1� <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 CENSUS TRACT <br /> s <br /> Owner's Name Phone Z2,00 <br /> Address l j a 0 E l-AA 2-M0- C,/t1 City 6-001 <br /> Go.)Joaquin Pump Co. License # �� �ts_��� <br /> Contractor's Name - (a;,irsm eg ssefl_;_,--..:,. 5,�..F ) 3�G3� Phoo ne - �� <br /> i <br /> y .5 <br /> TYPE OF WORK (Check) : NEW WELL -/-7 DEEPEN '/ / RECONDITION DESTRUCTION /- <br /> PUMP INSTALLATION /—/ PUMP REPAIR /C T- UMP 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 (!� <br /> Industrial Cable Tool Dia. of Well Excavation f <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /State Work Done G)(-7�ct �t5 isc� D 7 r N 7-u",,-Ve <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 AND INS E ION. <br /> SIGNED TITLE San Joaquin Pump Co. <br /> Cal <br /> DRAW P PLAN ON REVERSE SIDE of Ulfl '' " i` ': <br /> FO DEPARTMENT USE ONLY to-], Cai fosriiu 9:,244 <br /> PHASE I <br /> APPLICATION ACCEPTED BY , DATE T 1 i� 2 _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4r,7 DATE 1/ - ;--5 <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />