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FOE"'OFFICE USE; SAN JOAQUIN4JACAL. HEALTH DISTRICT <br /> �D 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone. (209) 466-6781 <br /> 6PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT p <br /> ermit No. <br /> THIS PERMIT EXPIRES 1 4Z-27,507 <br /> Complete I <br /> Application is hereby <br /> YEAR FROM DATE ISSUED Date Issued � <br /> --�' ( n. Triplicate} <br /> made to the San Joaquin Local Health District for a <br /> permit I and/or install the work herein described. This application is made in compliance twithnS nJo <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local an Joaquin <br /> Ibq Health District. <br /> JOB ADDRESS/LOCATION 770- / <br /> i <br /> So v �ti� JU CENSUS TRACT <br /> Owner's Name M �� <br /> S 1s/LG7,9a8&/Uphone L� - S�2z <br /> Address I <br /> City j <br /> Contractor's Name <br /> License #,2Phone <br /> TYPE OF WORK: (Check) NEW <br /> ,_WELL DEEPEN.- <br /> ALL /'/,_RECONDITI- - . DESTRUCTION /7. <br /> PUMP(INSTALLATION. / / PUMP REPAIR PUMP REPLACEMENT / r '`"� ' <br /> Other /% <br /> DISTANCE TO N IC <br /> EAREST: SEPTIC TANK SEWER LIMES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> PROPERTY LINE .. pyATE CESSPOOL/SEEPAGE PIT OTHER. <br /> ,INTENDED USE DOMESTIC WELL — PU$LTC <br /> TYPE OF WELL° DOMESTIC WELL p <br /> IndustrialCONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> ' Dflmestic/private I Drilled /- 1 /'` f <br /> Domestic/public _ Dia,_rvof_Well Casing <br /> Irrigation Driven �Guge of Casing <br /> Gravel Pack <br /> Cathodic Protection. Depth of Grout Seal . <br /> Rotary Type of Grout yz <br /> Disposal Other 'Other Information ' <br /> Geophysical. <br /> iiSurface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> IN H.P.. <br /> PUMP REPLACEMENT: <br /> _ / % State Work Done � <br /> PUMP -REPAIR: State Work Done <br /> 7ES'TRUCTION OF-WELT--Vill Diameter . <br /> . � <br /> De s;�cribe Material and Procedure Approximate Depth ------ --- <br /> L hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Ind .the State of California pertaining to or regulating well construction. Within Health <br /> FIFDistrict <br /> ifter completion of my worfk on a new well, I will furnish the San Joaquin Local Health District <br /> TELL DRILLERS REPORT of t9e well and notify them before putting the -well in use. . The above a <br /> nformation is true to thele;bbest o my-knowledge and belief. I WILL CALL ,FOR A GROUT INSPECTION <br /> RIOR 20 GRO N D A FIN ECT ION. <br /> IGNED � . <br /> DRAW PL T PLAN ON RE ERSETLE <br /> SIDE) - <br /> - <br /> RASE I �, FOR DEPARTMENT USE ONLY ; <br /> PPLICATION ACCEPTED BY / <br /> DDITIONAL COMMENTS: IM. DATE --a "5-- <br /> PHASE II GROUT INSPECTION <br /> NSPECTION.,BY ,-�.__ _._. PHASE III/FINAL INSPECTION <br /> --,;IDATE_,._. _ - _ ..INSPECTION. BY DATE -- 2- <br /> E H 1426 Rev. 1-74 ► ,, ` <br /> 3/76 2M <br />