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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br />` Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> _3L-5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made t1 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 /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner'sName L E�1`P 2-ci'' _%? i l_G�}tt.�" Phone ' clWe <br /> 1 <br /> Address '72 9 Q El aZ_2- 'd17 City C C)go <br /> Contractor's Name Sats Joaquin Pump Cc' . <br /> lVISIOn Or an _ .,.. c License # Phone <br /> Q� Cal'afr_=is 95240 <br /> TYPE OF WORK (Check): N4'ViLL / / DEEPEN /-� . RECONDITION. /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / , PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD , CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � . <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of , siWell Casing. <br /> jj Domestic/public _ Driven 1 Gauge .of- Cang <br /> - Irrigation Gravel Pack r- De th of r <br /> �� p Gaut Seal <br /> Other _ 1 Rotary, ,`Type of Grout <br /> Other' Other Information 1 <br /> PUMP INSTALLATION: Contractor 5-11__ acs-:crui,.�/ <br /> H.P <br /> Type of Pump '"� w, - <br /> P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP REPAIR-: :=�/­�/—S tate-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 f <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 thembefore` " putting the well in use. The above <br /> information is true to the best of my'knowiedge and belief,„ <br /> SIGNED V �v� TITLE <br /> San Joaquin PUMP Cu. <br /> DRAW PIAT PLAN ON REVERSE SIDE) ision of Son 7ooquin Sulphur o. F <br /> PHASE I FOR DEPARTMENT USE ONLY 71 . . �acrnnlG <br /> Lod6, California 95240 <br /> APPLICATION ACCEPTED BY DATE <br /> az21_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECT N t <br /> INSPECTION BY DATE INSPECTION BY DATE 7t� <br /> t <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. � <br /> E H 1426 7/72 1M <br />