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1X0 <br /> SAN JOAQCa,,,, <br /> # t . UIN LOCAL HE H DISTR�CT <br /> + . 4 <br /> FOVMCE U E: 1601 E. Hazelton Ave. , Stockton, Calif. { <br /> A Telephone; (209) 466--6781 <br /> § �. . <br /> /APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �s <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , .2 z-5— <br /> 4the <br /> (Complete In Triplicate) <br /> Application is hereb trade San Joaquin Local Health District for a permit to construct <br />��Iand/or install thew rk herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 andjj1the Rules and Regulations of the San Joaquin Local Health District. <br /> I I .ENSUS TRACT <br /> JOB ADDRESS/LOCATION Aaf <br /> Owner Ps Name Phone - _y-- -- <br /> r- City ,�/►A <br /> Address, <br /> I, <br /> Contractor's Name License Phone wtS' C� <br /> TYPE OF WORK (Check) : NEW WELL X DEEPEN '/ RECONDITION_/� DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT f7 <br /> { • Other <br /> DISTANCE TO NEAREST: SEPTIC DANK SEWER LINES PIT PRIVY <br /> - SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER C� <br /> PROPERTY LINE - PRIVATE'DOMESTIC WELL PUBLIC DOMESTIC WELL S <br /> INTENDED USE•��, TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial 4 1 Cable Tool . Dia. of Well Excavation <br /> 90 <br /> 4 Domestic/private.:_ Drilled Dia. of Well Casing <br /> Domestic/public ..-` Driven _ , ' Gauge of Casing . <br /> irrigation J ; ..'Gravel• Pack�f Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> j Disposal «-, , Other Other Information <br /> 1 Geophysical. s _ Surf ace Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Y� Type"of Pump H.P. <br /> REPLACEMENT:_ /' / 'xState-Work-Done -•`�" ..� <br /> PUMP RE _». � - -- - <br /> s <br /> m..Pi7I�...:REPAI&:-*-: Work Done`,, - - - r --•�� .� - _ <br /> ES;TRUCTION OF WELL: Well Diameter- Appxaximate 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 Californialpertaining to or regixlating well construction. Within FIFTEEN DAYS <br /> after coti�pletion of my work on a new well, I ;will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT o;f=,,;the ..well in use.. The above <br /> well and notify them before putting, the <br /> ] information is true to-`.,,.the,.:best-of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> { PRIOR TO GROUTING AND ''A FINAL INSPECTION. <br /> SIGNED 051A,mA TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br /> PRASE I DATE <br /> APPLICATION ACCEPTED BY - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT. INSPECTION P I FINAL INSPECTION <br /> INSPECTION BY r DATE J�c3-_7S INSPECTION BY DATE s-7PS: <br /> S <br /> 1-74 2M <br /> }� E R 1426 Rev. 1-74 - <br />