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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F09 WFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3 �o <br /> THIS PERMIT EXPIRES 1 YEAR FROM�DATE -ISSUED Date issued; <br /> .�s6 <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the Sealth District. <br /> an Joaquin Local.H <br /> L <br /> JOB ADDRESSAOCATION cQ ,5 QV CENSUS TRACT <br /> 'Owner's Name C� D Ro _ . $"^ <br /> Address one <br /> Cite �o�v <br /> Contractor's Name _' ,�,�yr c -< i ,LJ <br /> - Licensers phone <br /> TYPE OF 'WORK (Check):,�•NEW jWELL`/? DEEPEN _ ~' <br /> ` /7 RECONDITION /7 DESTRUCTION /, j <br /> } k{ PUMP INSTALLATION /7 PUMP REPAIR -/_7 PUMP REPLACEMENT <br /> Other,'/=/ - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL ELD CESSPOOL/SEEPAGE PIT. OTHER p` <br /> ` <br /> INPROPERTY LINE - PRIVATE WS-TIC WELL' PUBLIC f DOMESTIC WELL {" <br /> TENDED USE TYPE OF WELL MECONSTRUCTION SPECIFICATIONS <br /> ° Industrial Cable. Tool Dia. of Well Excavation � <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public '" ' � : LA <br /> Drive' <br /> k i; Gauge-.of Casing - I <br /> ----- Gravel'Pack °�'�Depth of Grout Seal r <br /> Cathodic Protection Rotary Type <br /> —Disposal Other Other Information <br /> Geophysical, — -- ± <br /> F� Surface Seal Ins tailed B <br /> PUMP INSTALLATION: "Contractor f. <br /> { <br /> +-'"._.,„Type .of Pump 1 <br /> H.P. <br /> PUMP REPLACEMENT: } j9 State Work Done <br /> PUMP :REPAIR: 4... -� o <br /> _77-S tate Work Donee ^` <br /> DESTRUCTION OF WELL Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure �— <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 well and notify them before putting.. the.-well. in .use.... .The above' <br /> information is true to- the-best-of. my..knowledge and' belief. I WILL .CALL 'FOR 'A GROUT <br /> PRIOR TO GROU G AND FI INSPECTION. INSPECTION <br /> SIGNED TITLE - <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR p4lip T USE ANLY } <br /> APPLICATION ACME LI a07-1_' DATE <br /> ADDITIONAL COMMENTS. A/ AL,- <br /> PHASE II GROUT INSPECTION • P II IN INSPBCTIO <br /> INSPECTION BY DATE INSPECTION BY ;Z" i <br /> DAYS <br /> E-H`'1426 <br /> Rev. � 1.-. <br /> 74 <br />