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l { <br /> SAN JOAQUIN. LOCAL'',HEALTH DISTRICT <br /> .LOB iOFFICE USE: 1601 E. Hazelton Ave'.""'-Stockton, Calif. <br /> Telephone: ' ,(,209)' '466-6782. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /bop <br /> THIS PERMIT EXPIRES 1-1-YEAR-FROM DATE ISSUED Date Issued <br /> (Complete :in Triplicate) # <br /> Application is'hereby made to the San Joaquin, L;ocal .Health District for a 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 San Joaquin Local Health District. . <br /> .TOB ADDRESS/LOCATION -7005- S. SOVw- 9&ZL -rA CENSUS TRACT <br /> Owner's Name F N A� A u Phone �a <br /> Address /4ya'k'e- __7= City G,q/vCYv <br /> Contractor's Name 7r. aAJLicense G2 NO z 0 Phone 92;PV {{ <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN '/_7 RECONDITION /_ .DESTRUCTION f7 <br /> PUMA' INSTALLATION / /_PUMP REPAIR j&­PUMP REPLACEMENT - 1-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . _PIT PRIVY <br /> SEWAGE DISPOSAL FfEI:I7 CESSPOOL/SEEPAGE PIT (}TIER <br /> PROPERTY-LINE =-`PRIVATE•-DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL .�Ye CONSTRUCTION-SPECIFICATIONS \ <br /> Industrial , Cable Tool. `� �Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven "-Gauge of Casing` <br /> Irrigation Gravel-,Pack ;Depth of Grout Seal : <br /> " Cathodic Protection Rotary - Type,+of Grout <br /> Disposal Other Other-'Information <br /> Geophysica] Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> TYPe of ,Pump H.P. <br /> PUMP.-REPLACEMENT:,:. , 1. <br /> /.r./...�:State Work Done <br /> ti. ork :C <br /> - <br /> PIM - - <br /> ,'State W xDone` `;" T <br /> E&TRUCTION OF WELL: Well Diameter 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 <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 FQR A GROUT INSPECTION <br /> PRIOR TO GROU NG AN A FINAL INSPECTION. <br /> SIGNEDcz <br /> TITLE ?�a <br /> {DRAW PLOT PLAN ON REVERSE1SI ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I `} <br /> APPLICATION ACCEPTED BY DATE ' 2-2 a��z <br /> ADDITIONAL 'COMMENTS: <br /> PHASE II GROUT 12WECTION # <br /> PHAS II INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ' E H 1426 Rev. 1--74 I-74 2M y <br />