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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. lp l <br /> THIS PERMIT EXPIRES 1 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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION , 12- 0 CENSUS TRACT <br /> Owner's Name - �. af.A Phone 9.3- 03-5- <br /> Address 13 <br /> 440 E I EjAL1j :Lt> City /ff#-AjT7!L C,& <br /> r <br /> Contractor'sl.,NameLicense # Phone -.5( <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN %/ RECONDITION / / DESTRUCTION /_7 W <br /> AL <br /> t PUMP IINS TLATION / / PUMP REPAIR/ / PUMP REPLACEMENT .� <br /> . . <br /> •Ii <br /> Other' / / •� <br /> t 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 o <br /> [ -USE• !TY,PE'OF WELL `� ' CONSTRUCTION SPECIFICATIONS <br /> �.� <br /> ,Indus tri: -- ---Cable-;Too3—Dia of We�1—Excavation-7 <br /> _ LX_Domestic/private, , \ _��Dx lled Dia-..-o.£ Well Casing; <br /> Domesti/public Driven Gauge of Casing <br /> Irrig'St-ion i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposd2 Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> t PUMP INSTALLATION: Contractor <br /> Type <br /> of Pump H.P. <br /> PUMP REPLACEMENT: State Work .D.one_(- vn1 ;—:4,AW <br /> PUMP .REPAIR: r- / / State Work Done � <br /> DES,TRUCTION"`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 /> I 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED, BY DATE��_,5 — 79 <br /> U <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT" INSPECTI N PHASE I INAL I PECTION <br /> INSPECTION BY DATE 6INSPECTION BY ATE Z S- <br /> _y E H 1426 Rev.- 1•••74 " _ 1/77 2M <br />