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�o,N JOAQUIN LOCAL HEALTH DISTRICT <br /> 16C� <br /> f FOE OFFICE USE: �/ . Hazelton Ave. , Stockton, Cay , <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PE PG6"b'nj5j <br /> _ <br /> THIS PERMIT EXPIRES l YEAR FROM D IL f � 9� <br /> ATE ISSU D -Date Issued �)� <br /> (Complete In Triplicate) <br /> Application is &ereby-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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION , <br /> f d QTc t1 71.01 S'�Jr' ! SUS TRACT <br /> Owner's Name <br /> PhoneG® <br /> Address �.. <br /> GaO/ <br /> Contractor's Name Son Joaquin Pump Co. city <br /> Division of Son Joacruin sulphorLicense # Y1471 <br /> 711 N. S <br /> Phoneacrament t "f, <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN'/_/ RECONDITION —PUMP <br /> / DESTRUCTION /_7AL <br /> PUMP INSTLATION /,./PUMP REPAIR '/—/ PUMP REPLACEMENT /? <br /> Other <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> SEWAGE DISPOSAL. FIELD _ PTT PRIVY <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL,SEEPAPUBLIC DOMESTICPITO HER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial— Cable Tool Dia, of Well Excavation (n <br /> Domestic/private Drilled Dia, of Weil Casing 11 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection . Rotary Type of Grout i <br /> Disposal Yp 1 <br /> Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> Y <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump lee t.r� <br /> _ H.P. C3 <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL. Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 GROUTtNfLAND A FINAL INSPECT <br /> SIGNED TITLE Saw loaf uln PUMD CO <br /> D W PL' T PLAN ON RE M SE SI EYDiv5i0A of an'Joaquin 5ulphur'Ca,) ,• 'I <br /> PHASE I . <br /> FOR DEPARTMENT USE ONLY "� ar, <br /> � _ } R..n�i, Gri,:r`vri:•'� 'r_::�;; �. <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPkCTION BY <br /> l ._ DATE 2 <br /> E H 1426 _ <br /> -�--Rev. 1-74 .� 376 2m i <br />