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: <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO OFFICE!-USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 5 <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION 'OR PUMP PERMIT Permit No. 71z— 7Grl <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application. is iereby 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 Rul s a d Regulations of the Sari Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 51uA kofjAdLpiken� CENSUS TRACT <br /> Owner's Name Amj. �fl fyrm5_- -- �d Van 5, .on�� Phone - <br /> Address - -,G2"-1-'4.&,A <br /> Contractor's Name &MllhaLicense ��agoi=� Phonetj[/i j�1�-5� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL ST DEEPEN /_/ RECONDITION / / DESTRUCTION <br /> ,. PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /� } <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK W SEWER LINES ZI,4_y- PIT PRIVY t, <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ; <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL Zf 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 <br /> Cathodic Protection Rotary Type of Grout ',v.�? g��_�, y ,, <br /> Disposal Other Other Information & r <br /> Geophysical Surface Seal Installed. By: <br /> PUMP. INSTALLATION Contractor <br /> Type of Pump H.P. <br /> l P01P REPLACEMENT: f / State Work Done ' <br /> IF <br /> II <br /> PUMP .REPAIR: State Work Done <br /> 3V, .. ...�.� ..,....-.<.- .. ..w - <br />' DES-TRUCTION OF WELL:•. Well' Diameter§� Approximate Depth <br /> r Describe Material an.4 Procedure <br /> 1 -jiereby agree to comply with all..law .and-regiAla- tiorrS of the San-. oaquin.-LocalaRealth 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 Distridt 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 x <br />`PRIOR TO GROUTING AND/A FINAL INSPECTION. -I <br /> SIGNED TITLE <br /> ---(DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE_ „ <br /> ADDITIONAL COMMENTS: ` <br /> PHASE II GROUT INSPECTION PHASE ISI/FINAL 'INSPECTION <br /> INSS(P�ECC ON BY DATE INSPECTION rBY DATE (�J <br /> LIr' W i"U ait T A 1 U3 0 Go' �, /'_ 1'--J-72M <br /> —E H 1426 Rev. 1--74 <br />