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4 <br /> x _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS.:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6.781 <br /> APPLICATION FOR WELL CONSTRUCTION"OR PUMP PERMIT Permit No. z6-/0,3,;t t E <br /> THIS PERMIT EXPIRES 1 YEAR FROM .DATE ,ISSUED , Date Issued <br /> J (Complete. In Triplicate) , : <br /> Application is hereby made to' the San Joaquin Local health Districtfor" <br /> .a permit to construct <br /> and/or install the work herein described. This application is nade, in" complianCe with San Joaquin-' <br /> County' Ordinance No 1862 and,-the Rules ap,d Regulations of the San. Joaquin. Lacal -Heal th District. <br /> JOB ADDRESS/LOCATION -S ��'S CENSUS TRACT <br /> Owner's Name 4 — Phone <br /> Address: J Z17Ae??1J4 G�,4_J6" �^ city / <br /> Contractor's Name - 'Sale Joaquin Pump Co. License" #�3ID�d Phone 3�i-,f V7f <br /> (INViliell of so gwlphup GO,) <br /> TYPE OF WORK (Check): NEW WELT, /7 DEEPEN j-7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION / PUMP REPAIR -7 PUMP REPLACEMENT // <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -ti- PIT PRIVY F <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 _ :Driven. _..- _ Gauge of Gasirig <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 B <br /> yf <br /> PUMP INSTALLATION: Contractor <br /> Type .ofi.'Pump H.P, . <br /> PUMP REPLACEMENT: /4 1 Cate Work Dane CGce lo mo to,E //)o c1%B/,f1 <br /> PUMP :REPAIR: <br /> / Staa <br /> te Work Done <br /> DESTRUCTION OF WELL: Well,Diamieter 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.. Withtn. 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 A FINAL INSPE2KI0 . <br /> SIGNED TITLE San loo- Iain Pum -Ca. <br /> CZ DRAW PIAT PLAIN ON REVERSE SIDE (Division of Sart Joaquin Sulphur eo.3 <br /> FOR DEPARTMENT USE 'ONLY 71.1 N. Sacramento St. <br /> PHASE i � � .. Lath, California:95240 <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/AMINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> - a <br /> E H 1426- 'Rev. _1-74 ��°" G }�,� !/' h/7K 2M <br />