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SAN JOAQUIN LOCAL HEALTH DISTRICT r -� <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. 7-s l' <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> Pp �- /Vh ��� �'� Gari <br /> JOB ADDRESS/LOCATION $EOptemER OF G, 6e, 7 R f _ CENSUS TRACT <br /> Owner's Name Vt Phone 8,f- q5�e <br /> Address <br /> City zp / <br /> Contractor's Name S°n Joaquin PUMP Co, License /Q37jl Phone,? 7� <br /> i.r` 4cA:g;rr�ia 95240 _ _ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION f-1 DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / f <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 o£; 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 .i! <br /> 7-411 �2 -11,e SG! <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU AND A FINAL INSPECTI , Scan foeruin Pump Co. <br /> SIGNED TITLE _ . <br /> llRAW PWT PLAN ON RE E'RSE SIDE - w'� <br /> FOR REPARTMENT USE ONLY Lsdi, Cclifa.rnia 95V4 <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 2- <br /> E H 1426 Rev. 1--74 <br /> 3/76 2M <br />