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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> F06 DFFICE 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 _ —7 <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 madein compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San 11 Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION !(1ps r a F / JY-;99 ME O- � 5 SP <br /> A1D CENSUS' TRACT <br /> Owner's Name T C —r Phone <br /> Address r - ,� City <br /> Son Joaquin Pump CO. License '# one <br /> Contractor's Name Z017-Ph <br /> $vision o -an Joaquin u p ur <br /> MY <br /> is <br /> TYPE OF WORK (Check) : NEW, WEd .7 DEEPEN/ / RECONDITION /� DESTRUCTION /? w N <br /> PUMP INSTALLATION / / PUMP REPAIR '/ '/ PUMP REPLACEMENT <br /> Other <br /> 5 <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 <br /> Domestic/private Drilled Dia. of Well. Casing <br /> Domestic/public brI.-V6n ""� 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 f/ H.P. <br /> PUMP REPLACEMENT: // State Work Done C r .�� �efiL �1u <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 /> t 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 no <br /> them before puttingwthe .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 OUTING AND A FINAL INSPE ON.. San Joaquin Pump Co, <br /> SIGNED "0W TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> ,� �C !d FOR DEPARTMENT USE ONLY l.oei, Cc"ifoaiiia 9;2�;Q. <br /> s� <br /> PHASE I DATE Z, <br /> APPLICATION ACCEPTED BY . <br /> ADDITIONAL COMMENTS: �— - --- <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 1-7-7 7 <br /> 3/76 2M <br /> R W 1 L 91; Rarr_ 1-74 <br />