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it r),( j!/ <br /> W"�' SAN JOAQUIN LOC*L. 5EALTH DISTRICT <br /> FOR OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. V__ �,_j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSbLD Date Issued z aa- 2 <br /> (Complete In Triplicate) <br /> Application is Aereby 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 L'Qpd j'>'— mde m W— za P11 CENSUS TRACT <br /> Owner's Name De, Phone ' s <br /> Address � City MtP <br /> Contractor's Name f - License 41 � '/, Phone` Q <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK •b' EWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL IELD 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 <br /> Domestic/public -� Driven Gauge of Casing <br /> Irrigation a Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout � � , oLtrt�Lrk/ <br /> Disposal Other Other Information a/,� A - <br /> -Geophysical Surface Seal Installed By: Q0 <br /> PUMP INSTALLATION: Contractor cE,d' v_- , <br /> - fw_y�.bA Type of Pump U H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 Bistrict <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 GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED t? rC�LS f���Ll ins n J-nd, tul TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHA I;0t.-ROIg INSPECTI N PH4SrZ OWFINALINSP C I N <br /> INSPECTION BYDATE INSPECTION BY DATE <br /> 2M <br /> E H 1426 Rev. 1-74 <br /> 1/77. _ ": <br />