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Vel: / SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> F0T1OFFICE USE. Y 1601. E. Hazelton Ave. , :Stockton, Calif. <br /> Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED .. Date Issued / ,z6 <br /> (Complete In Triplicate) <br /> Application is hereby'made t the San Joaquin Local Health District for a permit. to construct <br /> mrd/or install the work herein described. This application is made in compliance with San Joaquin, <br /> County Ordinance•No 1862 •aad the Rules and Regulatione. of ,.the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Eel if c- E iw�r-�1 �t. coo poe5 Cra eve CENSUS TRACT <br /> Owner's Name ' �+un KA� N` '- 43 y Phone '�Y2 <br /> Address . 1 U.7 S- AJ /�Lt1 Y % City.:.; ;_. <br /> Contractor's Name San Joaquin Pump Co, r License #3 Phone 362 a r i I <br /> u p ur .o. <br /> TYPE OF WORK (Check): NEW WELL r� tEEPEN •/? RECONDITION DESTRUCTION /7 <br /> PUMP INSTALLATION/—[,—PUMP REPAIR'/dTMP REPLACEMENT 17 <br /> Other <br /> .DISTANCE TO NEAREST: SEPTIGITANK SEWER LINES PIT PRIVY <br /> SEWAGEJDISPOSAL FIELD '' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE. DOMESTIC WELI:'- , PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1 <br /> Industrial t. Cable ToolDia. of Well Ecavarion �. <br /> Domestic/private-- .-t of'Wel.l .Casing` V <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout,. <br /> Disposal I Other Other Information <br /> Geophysical Surface Seal Installed 'By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. <br /> i <br /> PUMP REPLACEMENT: /7 State Work Done \, <br /> � i.cj b 1 i S vu,arae ra`-n-die &,2oL,- f_ (>a"p nJ <br /> PUMP 'REPAIR: �•-_/Lf_" _S.ta.te_Work Done - &Lq -��-,:v�Vic:l = pit v�' <br /> DESTRUCTION OF WELL: Well Diameter Approximate' Depih <br /> k Describe Material. and Procedure <br /> I hereby agree to comply with all laws and regulations of the Sari 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 /> f information is true to the best.of. my.knowledge and belief. I WILL CALL 'FOR A ,GROUT INSPECTION <br /> PRIOR TO GROUT G AND A' FINAL INSPECTIO . TITLE San Joaquin Pump Co. <br /> SIGNED n 395quin u p ur Co.) <br /> t DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY i`odi, .Caiifarnia 95;4 <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATEZL�. <br /> ADDITIONAL COMMENTS:' i. <br /> PHASE II GROUVINSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY .DATE iQ <br />