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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif.- <br /> Telephone : (209) 466-6781* <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PE No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 49p3 - 00- ,3Z <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 /> 0-g k H/- Jr-Arfr1.-7- 46-r <br /> JOB ADDRESS/LOCATION (0,047 tC c� e t �n ,� �^- W10 L_OeurC.c, 5pt- 0CENSUS TRACT <br /> Owner's Namef v C� Phone <br /> Address l r '.s City <br /> San Joaquin Pump Co, <br /> Contractor's Nam�l . . sulphur License # 3m379Phone �-�y-_ � � <br /> M <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION I / DESTRUCTION 1-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT 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 e <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: /tate Work Done LLIXA�'W'v10qj.,Y412,�/'f <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 /> 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 knowled and belief. I WILL CALF. FOR A GROUT INSPECTION <br /> PRIOR TO GROUTINGINAL�I SP an oaquan Pump o. <br /> SIGNED TITLE (Division of Son Joaquin Sulphur co,} <br /> (D P OT PLAN ON REVERSE SIDE) acramento St. <br /> F DEPARTMENT USE ONLY ' %CcULMnla 954%k <br /> PHASE I t <br /> APPLICATION ACCEPTED BY `� DATE 1 Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION U PHASE I/FI INSPECTION <br />,-INSPECTION BY DATE INSPECTION ATE <br /> E H 1426 Rev. - I-74 � °177 - 2M <br />