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y; SAN JOAQUIN LOCAL, HEALTN,;.DL,5,TRICT <br /> -IOR OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTIONOR.,PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ,'(Complete In Triplicate) -7v <br /> Application'is Aereby made to the San Joaquin Local Health District for a permit to const uct <br /> and/or install the work herein described. This application is made in compliance with San Joaquitt <br /> County Ordinance No. 1862 And th� Rules and atio3�s of tk*. uin Local Health District. <br /> : .. C'OI �►�- AV17 —d; Ll ve Ma oft6"cpow3 S <br /> JOB ADDRESS/LOCATION Acrross Fre..ra CENSUS TRACT Yf <br /> GoYT. 3s Tl,. sae -•ter • D <br /> Owner's Name Phone <br /> G <br /> AddresseCUlneorn1* Yjxi,V City 21 <br /> A.e <br /> J <br /> Contractolf ATE winLicense �t"Phone . o <br /> TYPE OF WORK { tllc�t� DEEPEN '/ I RECONDITION /-7 DESTRUCTION /7 <br /> T `+�V � ,TALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> ' Other <br /> DISTANCE TO' NEAREST:->:, SEPTIC TANK 44 SEWER LINES PIT PRIVY 5 . <br /> SEWAGE DISPOS ,FIELD Al CES POOL/SE PAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL AM PUBLIC D MESTIC 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 iM' •" �. <br /> Domestic/public �^ Driven Gauge' of°Casing"-1/G0 ..PVA <br /> Irrigation 1/ Gravel Pack ;� Depth of Grout Seal y7• <br /> Cathodic Protection - A." Rotary Type of Grout <br /> 7 Disposal ✓ Other g,� Other Information <br /> Geophysical Surface Seal Installed B <br />. PUMP INSTALLATION: Contractorx <br /> Type of Pump H.P. iu <br /> 4 <br /> PUMP REPLACEMENT: / / State Work Done . �1 <br /> PUMP ,REPAIR: /7/ State Work 'Done a <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material. and Procedure <br /> tI hereby agree to comply with all laws and regulations of the San Joaquin Local Health District C.jI <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 <br /> 'WELL DRILLERS REPORT of the well and notify them before.,putting the..well. in use.., . The above w� <br /> tinformation is tpV to the best of my knowledge and 'belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO RO D A FI AL INSPECTION. , <br /> SIGNED TITL <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLYPHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> �PEQ4ION BY DATE INSPECTION BY DATE <br /> �`' , 1177 _ 2M <br /> E 1426 - Rev- -' <br /> - <br />