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SANJOAQUIN LOCAL HEALTH DISTRICT <br /> FC'K FI <br /> OFCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> kTelephone : (209) 466-6781 p <br /> ` APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,0/- <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> i <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 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District'. <br /> i <br /> JOB ADDRESS/LOCATION'74,1 F CENSUS TRACT <br /> k Owner's Name Phone <br /> 4 ' IILY <br /> Address _Pmoij/1•y7, �, Q�„1,�-�.��^^�11., City <br /> Contractors Name License 4 �hon <br /> TYPE OF WORK (Check) : NEW WELL / // DEEP %/ RECONDITION /_/ DESTRUCTION /7 <br /> ALL <br /> T PUMP INSTATION YX PUMP REPAIR / / PUMP REPLACEMENT <br /> li Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES i PIT-PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC 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 <br /> Domestic./public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal F <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal. Other Other Information <br /> Geop�ysical Surface Seal Installed By : _ <br /> I <br /> 4 PUMP INSTALLATION' Contractor DJV <br /> Type of Pump zzH.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 wel.1''cbnstruction. 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 INSPECTION] <br /> PRIOR TO -GROU ING 4D 4 FINAL INSPECTION. <br /> ' SIGNED `jj fll�q042V TITLE ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ �__A <br /> DATE <br /> ADDITIONAL! COMMENTS: C-i -- t... o <br /> PHASE II GROUT INSPECTION PIM E III/FINAL INSPECTION <br /> INSPECTION RY DATE 1__, /-_7 _- INSPECTION BY0/1 DATE <br /> 01 7 K <br /> E H 1426 Rev. • 1-74 - - t7'l i d{ °� � ~ <br />