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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEOFFICE USE: 3.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.;15"- 3 6s,_10Y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5-1?-16 <br /> i <br /> (Complete In Triplic' Ate) <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 appl.ication­is made;.in compliance, with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of "the San Joaquin Local Health District.. <br /> i <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Ownera Name i Phone.Ra 9co I <br /> Address City . SC 14 L abJ <br /> --+ pp <br /> Contractor's Name "T , .I „/ a License # 79010 Phone gam' <br /> TYPE OF WORK (Check)! NEW WELL /? DEEPEN J7 RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION N PUMP REPAIR /7 `PUMP REPLACEMENT /7 <br /> � Other <br /> 5 <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 f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/ privateDrilled 'I `Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of. Grout Seal <br /> Cathodic Protection Rotary Type of Grout �s <br /> Disposal Other Other Information ' : <br /> Geophysical , -Surface Seal Installed B �1 <br /> PUMP INSTALLATION: Contractor D L4 4D � <br /> ` Type of Pump H.P. I <br /> PUMP REPLACEMENT: - / / State Work Done <br /> ,PUMP .REPAIR:- %�'/ State Work Done <br /> DESTRUCTION OF„WELL: Well Diameter Approximate Depth <br /> z Describe Material and Procedure <br /> .1 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 au a new well, I will furnish the San Joaquin. Local Health District a <br /> W- ELL .DRILLERS REPORT of the well and notify them before. putting.the..well. in.use.... .The above <br /> infarti�ation is true to- the,best-of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOE"T0 gPQUTING, AND A2PINAL INSPECTION. <br /> SIGNED r TITLE <br /> do DRAW PLOT PLAN ON REVERSE SIDE ; <br /> O ARTMENT Usir ONLY <br /> PHASE I <br /> APPLICATION` ACCEP. I-)NOT-1 DATE S <br /> ADDITIONAI;'COMMENTS:' <br /> PHASE II GROUT INSPECTION P IN SPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 'I_7A <br />