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~ t �-'A <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFR OFFICE USE: <br /> 1601 E. iiazelton. Ave.", 'Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. P:�= <br /> THIS PERMIT EXPIRES 1,YEAR FROM DATE ISSUED Date Issued <br /> f (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 /> /a o 5r,os ,y s 7- <br /> JOB <br /> rJOB ADORES$/LOCATION f$ yos . G�A-F& CENSUS TRACT <br /> Uwner°s Name f ... .t� <br /> C a ra Phone �'^ 7� 7o <br /> Address. .. <br /> City _Gcj v/ <br /> Contractor's Name License # Phone <br /> TYPE OF-WORK (Check); NEW WELL -7 DEEPEN ,/-7 <br /> REPAIR'RECONDITION /?PUMP REPLACEMENT /_7 <br /> DESTRUCTION (7 <br /> PUMP INSTALLATIONr <br /> T� I� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 5 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL- CONS <br /> TRUCTION SPECIFICATIONS <br /> Industrial Cable Tool ! �. Dia. of-Well Excavation <br /> Domestic/private Drilled , 'Dia. of Well Casing <br /> i, Domestic/public Driven Gauged.of Casing <br /> Irrigation Gravel Pack < Depth` of Grout Seal <br /> Cathodic Protection Rotary Typo-of Grout' <br /> Disposal ' Other Other- Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor 5, q.qA 1 <br /> # Type of Pump H.P. Z S" <br /> PUMP REPLACEMENT: E17 State Work Done <br /> P1rMpREPAIR': / Sty a W6 k_b_ <br /> ne <br /> — -^ �- <br /> . �I <br /> ,PES1RUCTION OF WELL: Well Diameter Approximate Depth j <br /> Describe Material and Procedure <br /> 1 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 j <br /> information is true to the-best-of my-knowledge 'and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSP ION. fan Joaquin Pump 'Co. <br /> SIGNED `� TITLE (Division of San Joaquin SuLuhur Cori <br /> DRAW PLOT PLAN ON REVERSE SIDE 500 E. Kettleman <br /> FOR DEPARTMENT USE ONLY o i, s o;nia 95240 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br />'� ~E <br /> H 1426 <br /> W Rev.- 1-74 1-74` M t <br />