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f,w - <br /> - W" J�/ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r FOR('OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> k Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 5'6 3J'Q <br /> d THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <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 /> G County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br /> !I 31w ; , '3 - c-�' J rwa,74 Jae f)w z 4 A it l CA ' <br /> JOB ADDRESS/LOCATION a& U/ - ,V CENSUS TRACT <br /> `Owner's Name - \�[f Com" Phone <br /> Address a 7�T- i <br /> city ts <br /> Contractor'a. Name --����--,, `� <br /> ' _ ,. Licensev-1dflJ.�Pharae. - b`' <br /> x'YPE OF WORK (Check) : NEW WELL/7 DEEPEN /7 ^ RECONDITION /-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / —PUMP REPAIR 0 PUMP REPLACEMENT /7 <br /> Other E/ — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT }OTHER <br /> 4 PROPERTY LINE = PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �. <br /> INTENDED USE TYPE OF WELL <br /> ---.-,CONSTRUCTION SPECIFICATIONS t� <br /> Industrial <br /> Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled rDia. of Well, Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation, Gravel Pack Depth of Grout- Seal 1 <br /> Cathodic-Protection- - -; ._ Rotary - Type of Grout <br /> Disposal'. :l Other_ Other Information <br /> Geophysical 'Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �- --H.P. <br /> PUMP REPLACEMENT: <br /> E7 State Work Done <br />'` POI+ .REPAIRt '""` State Work'Done <br /> z <br /> ES TRUCTTON 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 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 JfOR A -GROUT IN PECTION <br /> ,PRIOR TO GROU G AND FINAL INSPECTION. <br /> SIGNED ` - <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> �....,. ..� T=,...-��..-..M..�--_� _- R-DEPART-HENT ,USE•ONLY,.,......_. ,,.-�,�_.--....�. .� - _' <br /> PRASE I , <br /> APPLICATION,ACCEPTED BY +," �� ' ' DATE <br /> admxADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAU FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATE " 27 7Jj <br /> i E H 1426 Rev. 1-74 <br /> 1 .74 2M <br />