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't SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOP OFFICE USE: 1601 E.. Hazelton Ave. , Stockton, Calif. A-, <br /> Telephone: (209) 466-6781 <br /> .:APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 50 <br /> THIS. PERMIT: EXPIRES I YEAR FROM DATE ISSUED Date Issued 7 <br /> ( <br /> Application is here made to the -San Joaqu n,.L calrHealth District for a permit to construct <br /> 4 and/or install the wor 'erein described... This application is made in. compliance with San Joaquir <br /> County Ordinance No. 1 62 Rules and Regulations, of the San. Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S�' Q .0 C CENSUS TRACT <br /> I Owner's Name S b Phone : <br /> Address C3 City <br /> Contractor:s Name Q`e�r <br /> 'C \ �'S License # a (p WSSPhone 3(6"F-2jg'b <br /> 5 <br /> TYPE OF WORK (Check) : NEW WELL /�/ DEEPEN /% RECONDITION /�/$ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY .LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE GOP 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 f <br /> I Irrigation Gravel Pack Depth of Grout Seal, <br /> Cathodic Protection d Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical !1 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of 'Pump , H.P. <br /> PUMP REPLACEMENT <br /> / / State Work Done <br /> IPUMP .REPAIR: / / State` Work Done <br />` DESTRUCTION OF WELL: Well Diameter. rr Approximate Depth <br /> Describe Material and Procedure r <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 /> r after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT ofiithe well and notify them before putting thewell in use The above <br /> information is true to the best of my knowledge and belief. I WILL_,_CALL. FOR A GROUT INSPECTION <br /> PRIG 0 GROUTING iFINAL INSPECTION. <br /> SIGNE ' <br /> TITLE � <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br />' APPLICATION ACCEPTED BY !:A:::A- , DATE 6 <br /> ADDITIONAL-COMMENTS: <br /> f PHASE II GROUT INS CTION., :� PHA II/FINAL INSPECTION <br /> INSPECTION BY DATE ' ` -INSPECTION BY DATE 77-1-71 <br /> E H 1426 Rev. - 1-74., 2M <br />