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SAN JOAQUIN LOCAL HEALbi DISTRICT " <br /> FOR,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. G �r <br /> i THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued '71 <br /> 'M <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 Joaquir <br /> County Ordinance No'. 1862 and the -Rules-and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ 1�1�, CAQ PoOrjU T 0,2 A 1). CENSUS TRACT <br /> Owner's Name (JRN ,2 Uz-�— Phone 4/706 <br /> Address �4 Q p)( L� 7,5� City _ 'Z0C M.0y <br /> ------ -- <br /> Contractor's Name License_.�Ezj7+4 Phone ' yg_g�`j 7_ <br /> TYPE OF WORK (Check).,: NEW WELL /. / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /-7. <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT / <br /> ' Other / /tel <br /> i DISTANCE TO NEAREST: SEPTIC TANK r. SEWERi LINES,. ,,�, PIT PRIVY .. .0 <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 /> f Industrial ' ; .Cable Tool art--Dia.-•-of Well Excavation <br /> Domestic/private;. Drilled :Diad "of 'Well Casing <br /> s Domestic/public Driven [ Gauge of' Casing <br /> Irrigation Gravel Pack "'"'Dep`th of Grout',Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal -_- _.. Other C Other Information`• <br /> Geophysical ! y� Surface Seal Installed By _!_ ____ <br /> r PUMP INSTALLATION: Contractor /J <br /> Type of- Pump 1 s H.P. / <br /> € PUMP REPLACEMENT: State. Work Done _p11J� .t//,� SUdE.PS1�LE /.f/.4 0< /{� d� <br /> PUMP .REPAIR: / / . State Work Done <br /> DESTRUCTION OF WELL: "Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r , <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 DAIS <br /> ,'. after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT 6'f the well and notify them before putting the well in use.. The above <br /> information is true t4 the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AjD AININAL INEC TION. <br /> SIGNED TITLE <br /> (DRAW PLOT'PLAN ON REVERSE SIDE) .' <br /> ljiLz�C <br /> DEPARTMENT USE ONLY j <br /> PHASE I <br /> APPLICATIOk ACCEPTED B. DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY i. DATE INSPECTION BY Z-5n DATE 4-f�4' <br /> i <br /> E H 1426 Rev. l=.?4 117.7 <br />