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i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` FOR OFFICE USE: V<601 E. Hazelton Ave. , Stockton, Calif. <br /> �# Telephone:,, (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7s'901 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 l _7S" ; <br /> (Complete In Triplicate) 00(- P-70-(t, <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 o •the an Joaquin Local Health District. <br /> JOB AD RESS/LOCATION Sc.����� S.c�e a c�G�a� Glkr� 0114f) CENSUS TRACT <br /> Owner's Name Phone <br /> Address _� �`I All � <br /> city S% c,/—la-tJ <br /> Contractor's Name License # Phone <br /> j .. <br /> t <br /> TYPE OF-WORK (Check): NEW WELL /77 DEEPEN /7 PRECONDITION-/ -DESTRUCTION---/? <br /> PUMP INSTALLATION 72-UMP,,REPAIR•/' J PUMP REPLACEMENT 1_7 <br /> Other <br /> .,, _ ,r�"t#.�' Wadi• , F - � � <br /> DISTANCE TO NEAREST: SEPTIC TANK sEkER LINES PIT PRIVY �� t <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE .PIT_ OTHER k <br /> INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATIONS ; <br /> Industrial Cable Tool <br /> r Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge; of Casing <br /> Irrigation Gravel Pack Depth* of Grout Seal <br /> Other Rotary ,De <br /> of"-Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor _a� ,At u ) A P [? c+ �_�, � <br /> Type of Pump Y�C.a. TA '1,.S c•r_ H.P. <br /> PUMP REPLACEMENT: /_7 state Work Done <br /> PUMP REPAIR: J J State`Work Done <br /> ESTRUCTION 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. Son Joaquin Pump Co. <br /> (Division of Son Joaquin Sulphur Co.) <br /> SIGNED "� rr TITLE 0 E. Kettleman <br /> (DRAW PLOT PLAN ON REVERSE SIDE i, a i ornia <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ,r - <br /> ADDITIONAL COMMENTS: --YTJ� 06 �c vr<t� =�Y e2 <br /> PHASE II OUT INSPECTION PHASE II FINAL SPEC N <br /> INSPECTION BY� DATE .INSPECTION BY DATE <br /> r <br /> CALL FOR A GROUT INSPECTION. PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM 1 <br />