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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. nazelfon Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,_f IN� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 8' <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 /> 'Ohdr <br /> JOB ADDRESS/LOCATION ' f e Sbeef'f3r-)pfe t,7 Vopd Z- -d CENSUS TRACT <br /> Owner's Name T. Co"'..7 �6 ltJ�s. Phone <br /> Address 114ZE4- -roy - " _ - city W-06<-701'11 <br /> R E. (9/6) <br /> Contractor's Name Aloaw y 7AeE/F C- z)zoc_1S7S License # . /Q (S Phone 37/•- 823f� <br /> IL <br /> TYPE OF WORK (Check) : NEW WELL -/K/ DEEPEN '/—/ RECONDITI'ON '/7 "DESTRUCTION-'/,/ Q <br /> PUMP INSTALLATION / / PUMP REPAIR- / / PUMP REPLACEMENT /7 <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 3'' <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public )< Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ,er'// d f� <br /> Cathodic Protection >C Rotary Type of Grout _ <br /> Disposal Other Other Information <br /> TX Geophysical Surface Seal Installed By: Moore T"er <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump T - H.P. <br /> PUMP REPLACEMENT: . /_7 State Work Done �l <br /> PUMP .REPAIR: / / State Work Done _ T <br /> DESTRUCTION OF WELL: Well Diameter .3 r Approximate Depth .510 Ff. <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 we11•'construction. Within FIFTEEN DAY <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <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 INSPECTIONA <br /> PRIOR TO GRO G D A FINA10, INSPECTION. <br /> SIGNED TITLE EH <br /> D W POT PLAN ON REVERSE SIDE <br /> FOR DEP TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE J� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECT OTV 2P <br /> INSPECTION BY DATE INSPECTION BY DATE <br />�'.•�E H 1426 Rev. 1-74 <br /> 3/76 2M <br />