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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS:'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. D <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�(- Gv <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,'] <br /> r x (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 /> SC.nuinty Ordinance No. 1862 and the Rules' and Regulations of the San Joaquin Local Health Di:-strict. <br /> JOB ADDRESS/LOCATION? 301 Nvrth Hwv 4 and dile Easy Stazi3_ey Road CENSUS TRACT <br /> Owner's Name 'gym. Sc h! Phone , <br /> Address. P. O. ,Box 143 Farmington, Calif. City <br /> -Contzactor's Name Furviance Urillira,P.O.Bax 64, Linden,UlAticense #240107 Phone 931-4468 <br /> TYPE OF WORK (Check,)i NE;VWELL'/_7- DEEPRN"ft'"7_'`RECONDITION I�f -DESTRUCT'-1.= <br /> PUMP INSTALLATION ,/ PUMP REPAIR/� PUMP REPLACEMENT x%]" <br /> Other ./ / <br /> DISTANCE TO NEAREST. SEPTIC TALK 2501 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 : x -Cab1e'To6l"- Dia. of Well Excavation <br /> Domestic/private Drilled Dia.. of Well Casing s <br /> Domestic/public Driven Gauge Gauge o£ Casing <br /> x Irrigation <br /> Gravel Pack Depth- of Grout Seal <br /> Cathodic Protection Rotary �� Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed Bv: <br /> Pump INSTALLATION: <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . <br /> /�r/ � State Work Done<--die-instatiZ-, O.IMP Turbine..-.-.. <br /> PUMP,,REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter . <br /> Approximate Depth, <br /> Describe Material and Procedure r <br /> jI 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.. . .They above <br /> e.information is true to the-best of- my knowledge and belief. I WILL CALL FOR A'GROUT INSPECTION <br /> (PRIOR TO GROUTING D INAL 'INSPECTION. <br />,'M$IGNED TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SID-Eyf <br /> : . DEPAR MENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTSC M fr DATE '7, <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III FINAL INSPECTION <br /># NSPECTION BY DATE INSPECTION BY DATE ; - o - <br /> f - f <br /> E H 1426 Rev. 1-74 F l�/7� 9tut <br />