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t _ t ��) SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR, OFFICE -US : 1 N''1601 E. Hazelton Ave. Stockton Calif. <br /> Telephone: (209) 466-6781 F <br /> M APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.;��� <br /> I� , <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaquin i <br /> County O dinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. 4 <br /> JOB ADDRESS/LOCATION / h - �r �' B. ( --GENS S TRACT <br /> �N <br /> Owner's Name Phone FIL 7930 <br /> i <br /> Address- I� City . <br /> h � <br /> Contractor s Name /(Q License # Q / Phone <br /> N - i� <br /> ,i <br /> TYPE OF WORK (Check) : NEW WELL /�7 DEEPEN /_/ RECONDITION /� DESTRUCTION /� , s <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br />: DISTANCE TO NEAREST: SEPTIC TANK SOO SEWER LINES 4- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER WC-U--50 o <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL N <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �} <br /> Industrial Cable Tool Dia, of Well Excavation ` f <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> F _Ca,hgdicj� Zection ✓ .Rotary YT Type ofGrout <br /> Disposal Other `- 0�►er Informaion - - <br /> Geophysical Surface Seal. Installed B <br /> PUMP INSTALLATION: Contractor�j_ {� � A <br /> ' <br /> Type of 1 -_tum ,,. d H.P. <br /> PNS pc.,y vt <br /> PUMP REPLACEMENT: -' / / State Work Done <br />' PUMP .REPAIR: / / State Work Done <br />'DES.TRUCTION=OF,,W.ELL: Well Diameter ,. ! - ~ ` Approximate Depth <br /> ' `� escribe Mate ri °and Procedure <br /> r ,- _ � <br />; I• hereby agree to comply with a 1, aws.and_.reg ations of he San Joaquin Local Health :District <br /> and, the State*"'6f Califo. is pertaining tq "or. regulating well '-construction. Within FIFTEEN DAYS <br /> jafGer 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 /> 4iriformation is- true to the best 4f my knowledge and belief. I WILL CALL FOR A GROUT INSPECTI <br /> .PR-DRY TO jGROUTING AND INAL I PECTION. <br /> SI`tUNED t ,{ TITLE <br /> Fr �. (D FA9 PLO -PLAN ON RE RSE SIDE) <br /> a FOR EPARTMENT USE ONLY <br />, PHASE I .�� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR T INSPECTI N PHAS F <br /> III.I/OINAL,INSPECTTON <br /> , INSPECTION BY Q DATE INSPECTION BY DATE, Z <br /> f <br /> ` V 1177 . 2M <br /> 6a E H 26 Rev. 1-74 <br />