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x Y <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> FORlOFFICE USE:' 1601 E. Hazelton Ave. , Stockton, Calif. # <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR 'UMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued cA-3-7q- f <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 Joaquinl <br /> County Ordinance 'N'o.. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 30B ADDRESS/LOCATION C A ,U CENSUS TRACT <br /> Owner's Named f i�f> , �Q S d�. Phone (N B'C;?c3 tS� <br /> Address City 4se <br /> Contractor's Name , r. -Phone- g3&aZ>j,7 <br /> -License=. <br /> { <br /> TYPE OF WORK (Check) : NEW WELL '/ • DEEPEN /? RECONDITION /? DESTRUCTION-f7 <br /> 3 PUMP,INSTALLATION / / PUMP REPAIR IN PUMP REPLACEMENT EY <br /> :'Other. - <br /> Vim+-N of V. lII1i t <br /> DISTANCE TO�NEAREST: ' SEPTIC TANK SEWER LINES <br /> SEWAGE <br /> PRIVY v <br /> -.-,.:..r-_ <br /> SEWAGE DISPOSAL FIELDT"` CESSPOOL/SEEPAGE PIT ' OTHER <br /> 'i PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial .: Cable-Tool Dia. �of We11.,Excavatian <br /> I„ tDomestic/private lledUla. of Well Casing <br /> Domes tic/public: Driven ,` Gauge of-Casing <br /> Irrigation Gravel Pack Depth ,vf. Grout Seal <br /> Cathodic Protection ''` Rotary~\' Type.of Grout <br /> Disposal . Other, Other Information <br /> Geophysics] ;:Surface Seal Installed By: } <br /> 'UMP INSTALLATION: Contractor ` ¢ <br /> Type of Pump e H.F. <br /> PUMP REPLACEMENT: - 3 <br /> State. Work Donees � <br /> "PMREPAIR: _ / S•tate�Work Done --"k2 <br /> PES•TRUCTION OF WELL: Well Diameter Approximate Depth. f <br /> Describe 'Materialland Procedure <br /> ;.N <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"we'll and notify them before putting-the well in use.. . The above <br /> information -is true to x`the,-beat of- my knowledge and belief. I WILL CALL FOR -.A 'GROUT INSPECTION <br /> PRIOR TO GROUTIN ANDA FI°N INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I <br /> APPLICATION ACCEPTED BY DATE Y Z -- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONHOE I A/ NAL INSPECTION <br /> INSPECTION BY. ATE INS N DATE <br /> 1 E H 1426 Rev. 1-742 <br /> 1=14 .- M <br />