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�w <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I FOR'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i Telephone: (209) 466-6781 <br /> I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM .DATE ISSUED Date Issued <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 Joaqui <br /> I County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> C,457- S'AOC vF �{1o��is/ Likvr.� S�r.Pi4 G uTc4 <br /> JOB ADDRESS/LOCATION ,Vele_ yip /�t ,per ��� CENSUS TRACT <br /> Owner',s Name Phone 33V_ -e)V/ <br /> Address . �2 q00 A�, 2 �'i�1cle,9 City <br /> San Joaquin Pump Co. <br /> Contractor's Name <br /> (Division of San Joaquin Su:phur Coa License ;0 Phone 3 G = 5�7 <br /> 71 1. N. SIICrIIment0 t.. <br /> _ L.o !, fF f a.rnla. 7 <br /> TYPE OF WORK~(Check): NEW WELL /_7 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 /> !I <br /> INTENDED USE WE <br /> 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS N) <br /> Industrial Cable Tool Dia. of Well Excavation � <br /> Domestic/private !4 Drilled Dia. of Well Casing Q <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> y� Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> 4 Typefi"of Pump rt H.P. <br /> PUMP REPLACEMENT: V/wy�l��.I/ ; State Work Done <br /> I L <br /> PUMP REPAIR: / /- 'State Work Done <br /> � ,DESTRUCTION OF WELL: Well Diameter Approximate DepJth- <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 anew well, I will furnish the San Joaquin Local Health Distridt <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. <br /> San Joaquin Pump Co. <br /> SIGNEDJ7 _j TITLE (Division of San Joaquin Su:•phur Co.) <br /> DRAW PLOT PLAN ON REVERSE SIDE ' <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY I YA? DATE <br /> ADDITIONAL COMMENTS: a <br /> PHASE II G OUT INSPECTION PHASE IIIIFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. - <br /> E H 1426 <br /> L 7/72 1M <br />