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"' '• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 'W'� � 1601 E. Hazelton Ave. , 'Stockton, Calif. <br /> Telephone : (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /yG <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin. Local Health District fora 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 /> f <br /> JOB ADDRESS/LOCATIONon LQ CENSUS TRACT <br /> Owner's Name A .,t Phone 1&3 - 233C <br /> Address City -5:tKP_. <br /> Contractor's Name <br /> License # Phone Mrs 33ST3 <br /> TYPE OF WORK (Check-) :_NEW WELL v/ / DEEPEN, /—/ RECONDITION /_/ DESTRUCTION /-T <br /> PUMP INSTALLATION / '7 PUMP 'REPAIR_/y/ PUMP REPLACEMENT /7 <br /> -- ----�- <br /> Other--/—/ <br /> DISTANCE TO .NEAREST: SEPTIC TANK/dC> 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 Cable Tool Dia, of Well Excavation <br /> Domestic/private - -;Drilled Dia, of Well Casing f` <br /> Domestic/public ¢ � Driven Gauge of Casing <br /> Irrigation K Gravel Pack Depth of Grout Seal ' 1 <br /> Cathodic Protection "' >w-"- Rotary —Type of Grout 4 <br /> —Disposal "-,.,,Other Other Information <br /> 4 Geophysical Surface Seal. Installed By-: <br /> PUMP INSTALLATION: Contractor �^_ V <br /> Type of 'Pumpa-LA 42 H.P. <br /> PUMP REPLACEMENT: / /` State Work Done `�x <br /> PUMP -REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - Approximate Depth " <br /> Describe Material and Procedure - <br /> f <br /> I hereby agree to comply7_dith' all laws and regulations of the San Joaquin Local Health District <br /> and the Stat& 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 insuse..,{' The above <br /> information--is-true -to the--bes't-of-my, knowledge and` belief I WILC CALL FORA GROUT INSPECTION <br /> PRIOR TO G OUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) - <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE G 7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE jL_:,k7`77 INSPECTION BY DATE <br /> 4 . <br /> E H 1426 Rev_ . 1-74 v,�%� 2M ?'� <br />