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a U ho--�,A; OAQUIN LOCAL HEALTH DISTRICTS <br /> F.OE OFFICE USE: 2601 E. Hazelton"'Ave. , Stockton, Calif. ,; <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued: a:_ j <br /> (Complefe 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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3 t?to 7 ` 2-d _ CENSUS TRACT <br /> Owner's Name /V C / Phone <br /> -3 90 <br /> Address " City <br /> Contractor's Name <br /> License # Phone ' <br /> U <br /> TYPE OF WORK (Check) NEW WELL '/ / DEEPEN '/_/ RECONDITION. / /f <br /> DESTRUCTION /� <br /> : <br /> PUMP INSTALLATION &H PUMP REPAIR / /,j,PUMP REPLACEMENT /� <br /> Other <br /> i t V . <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 /> r INTENDED_,USE TYPE OF WELL �cc,.�� CON TRUCTION SPECIFICATIONS <br /> Industrial f Cable Tool Dia'. ofT ell Excavation <br /> Domestic/private Drilled , 'D : ofiWell Casing <br /> -. Domestic/public a Drive. ' Gauge ,o€_Casing <br /> Irrigation Gr atk -Depth of Grout Seal <br /> Cathodic Protection.:- Rotary. Type Groin <br /> f <br /> Disposal �, ,/ Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type` of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done `f 0 _ \ <br /> ! PUMP .REPAIR: / /. State Work Done . <br /> a-- <br /> 11 <br /> DESTRUCTION OF WELL: Well ameter . k I . ! ; Approximate Depth ,. �J <br /> I Describ�Material andIProcedure' <br /> Y . <br /> I her 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 woxk on a new well, T will furnish the San Joaquin Local Health District s <br /> 4 WELL DRILLERS REPORT of the well and notify them befoie putting the .well in use. The above <br /> information is true to the!best of my knowled'geltand be2ie'f:'"`I-WILL CALL FOR A GROUT INSPECTION <br /> I PRIOR TO GROUTING AND A FINAL IN ECTION. <br /> SIGNED TITLE <br /> t DRAW PI: T PLAN 'ON RE FRSE SIDE <br /> FOVp DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P III INAL DATE <br /> SPECTI <br /> INSPECTION BY E DATE INSPECTION B�/ DA7 <br /> 3/76 2M 7< <br /> E H 1426 ae 1-74 <br />