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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOE OF-F.ICE USE: 1601 E' Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> AP tICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f ' 3_a91 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> ,4,:��p (Complete In Triplicate) (�j$7 - fID- t$ <br /> Application is`baereby"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 /> ERsr or 4902U6tt-1a, ISt Pump .uc},rrN sin6 4, = KIRif1UPA1,MA U.J 2!7 <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> t Owner's Name _Q _#'VI A 2 14 A20 i t Phone <br /> Address f f i jo M , pv� 1E 2 D _ City <br /> Contractor's Name SJn Joaquin Pump CO. License # ,M,37f(Phone - <br /> qv <br /> Z <br /> TYPE OF WORK (Check) : NEW WELL-/ / DEEPEN /_/ RECONDITION /_/Q DESTRUCTION /-7, <br /> PUMP INSTALLATION ID 1UMP REPAIR '/—/ PUMP REPLACEMENT /-7 <br /> Other <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 y, �.- <br /> E Industrial Cable Tool Dia, of Well Excavation. -:., <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domesiic/public Driven Gauge of Casing <br /> QIrrigation z - Gravel Pack Depth of Grout Seal <br /> Cathodic Protection" ',+-L- Rotary-- -- - -Type of Grout <br /> j Disposal 1 Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contr a ctor ---_- <br /> Type of Pump H.P. <br /> E ' <br /> PUMP REPLACEMENT: / / State Work Done <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 'mconstruction. 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 thewell in use. The -above <br /> information is true to the best of my..knowled a and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTiNG, FINAL I SPECT��& <br /> Son Joaquin Finn Co. <br /> SIGNED TITLE Q p <br /> ' PLAN ON REVERSE SIDE °` °a n . <br /> 0 �-' F,� JASPL�7-/ ft <br /> FO�t DEPARTMENT USE ONLY u.Yfzrraia 35240 <br /> PHASE I �Jr} <br /> APPLICATION ACCEPTED BY DATE 'Z_ 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIOW PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY . DATE �. j n <br /> E H 1426 Rev. 1-74 : 376 2M <br />