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SAN JOAQUIN LOCAL HEALTH DISTRICT - l- <br /> LOS,OF&ZCYA UW, 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1A V Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP Dt No. TS--/,� 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> Za <br /> JOB ADDRESS/LOCATION A4 is 14 IF CENSUS TRACT-�-`f?- 02-0-07 <br /> Z <br /> Owner°s Namet�..���-1 Phone <br /> Address a ry 2zoi� -�- ... City <br /> Contractor's Name License # /,20,7- T <br /> 2 Phone4S ""- �"'2�� <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /2 RECONDITION /7 DESTRUCTION 17 S� <br /> PUMP INSTALLATION /—/ PUMP REPAIR /-7 PUip REPLACEMENT /f <br /> Other <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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing p <br /> Domestic/public Driven ` Gauge of Casing A;,k <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: -Contractor rf `r W LL If 95 � � rJ�"/!�!a W6X.LS_ <br /> . Type of Pump H.P. <br /> PUMP REPLACEMENT: / ./ State Work Done <br /> PUMP REPAIR-:- /-7- State --�" <br /> _ - Work Done _ <br /> ES-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 /> 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 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS& II FINAL INSPECTION �. <br /> INSPECTION BY DATE INSPECTION BYlde,., DATE ;-- ,2 - '7.5 <br /> ^E H 1426 Rev. 1-74 1-74 2M <br />