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` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ;OFFICE USE: L1601 E. Hazelton Ave. , Stockton, Calif. 76- 15 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �'I= F_1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -a41!?Sr <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 /> rel • i CIGVO'v6_� T C& Lia2 i�d �rvos� de <br /> JOB ADDRESS/LOCATION _e :2CX- � r-Znytj CENSUS TRACT <br /> Owner's Name IP-% . C,ha iz - Phone (, 7 <br /> Address ,�,`l Aj, ;5,9 t.rc ic�� R� � <br /> Joaquin rump o. City /�C lit i n <br /> Contractor's Name jDivision of San Joaquin Sulphur Co.) License U , Phone <br /> DUO E. Keldu=n <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN -/7 RECONDITION /7 DESTRUCTION /_7 - <br /> PUMP INSTALLATION /_/ PUMP REPAIR 1_7 PUMP REPLACEMENT f <br /> other /_7 <br /> 'r- <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 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: , X.I State Work Done <br /> PUMP '.REPAIR: /7 State Work Done <br /> 1]ES•TRUCTION 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 j <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <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 G OUTING AND A FINAL INS CTION. $tin Joaquinump,Lo, <br /> SIGNEDI., / � : <br /> TITLE IQ1Ylsion of San Jaagain Sulphur Co.) <br /> (DRAW PLOT PLAN ON REVERSE SIDEF SOD E. Kettleman <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY L001, a i orniq 954w <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II UT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY e5P DATE / 7 <br /> E H 1426 Rev. 1-74 .' 11— tl7q 2M .� <br />