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4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OFEI.CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> E APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L 3320 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l 1�Z1L <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 /> j County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION esl e_4 Ej2 CENSUS TRACT ' <br /> Owner's Name aid Phone ' -1 7,,;L y- -� f c <br /> f Address P e S / AO &6y. <br /> Coatractor'.s Name ��� .. License #CA22Phone 466-q-6 " <br /> TYPE OF WORK (Check): NEW WELL '/7 DEEPEN /7 RECONDITI01 -7 DESTRUCTION f7 <br /> PUMP INSTALLATION Lr7 PUMP REPAIR / J PUMP REPLACEMENT 17 ` <br /> Other /-7 — ! <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 OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well E cavation <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 t <br /> Disposal Other ► Other Information ' * <br /> Geophysical ` y fSurface Seal Installed By: <br /> f PUMP INSTALLATION: Contractor ._ <br /> Type of Pump H.P. - <br /> PUMP REPLACEMENT: • / / State Work Done <br /> _ <br /> PUMP .REPAIR '1A/ State Work Done <br /> k 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 we11 'construction. Within FIFTEEN DAYS <br /> after completiq of my work on a new well, I will furnish the San `Joaquin Local Health District a <br /> F WELL DRILLE RE �'A <br /> PO of the well and notify them before putting- the.-well. in.use... .The above <br /> informatio is tru the-b' of- y.knowled_ge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> I. <br /> s PRIOR TOG 0 T N BION. <br /> SIGNED / TITLE - .�_,r" <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FO . DEP TMENT USE ONLY <br /> PHASE I :��, <br /> APPLICATION ACCEPTED BY DATE., 12, X? <br /> ADDITIONAL COMMENTS: . <br /> PHASE, II GROUT INSPECTION PHASE II F INSPECTI <br /> k INSPECTION BY DATE INSPECTION BY DATE / <br /> E H ].426 <br /> Rev. 1-74- <br /> r /?5 2M <br />