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j SAN JOAQUIN LOCAL£HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , ' Stockton, Calif. <br /> Telephone:` {2b�) :46b-6781 <br /> APPLICATION FOR WELL. CONSTRUCTION''OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES- 1'YEAR' FROM DAT-E=ISSUEV Date Issued <br /> r <br /> (Coi' lefe In Tfiptieate) A <br /> Application is•hereby made to the Sa'n .Ioaqui:n Lo;(�:Al Health 0is.rtict=for a.permit to construct <br /> and/or install the work herein described. This .1plica.tion'� s' made in :compliance with 'San Joaquin <br /> Count��`6rdinance' No:. 1862---atcd the Rifles- acid Ro_-gulatl_bns10f- the- San"Joaquin Local "Health SPistrict,:=3 <br /> JOB ADDRESS/LOCATION g/j/ /DSL7/Gt`l� Rb �S7OF",�'GL/a77 . CENSUS TRACT <br /> Owner's name [j ���-R s('i=�`fE gib` `7,;/�/ �`/f/C phone ef6�t/ � 79-' <br /> Address 3 5-.2 7 City S <br /> Cod tractor's Name /t12 ' �(/ Licernse: #.2 G/6 Phone '? <br /> TYPE OF WORK (Check) NEW WELT. DEEPEN /T/ RECONDITION /_� : DESTRUCTION /— )k3 - <br /> _7 <br /> P.LMPII INSTALLATION / / PUMP REPAIR Ll PUMP REPLACEMENT f-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC 'TANK._, SEWER LINES` PIT"PRIVY <br /> SEWAGE -D''ISFOSA FIELD . .CESSPOOL/SEEPAGE.PIT OTHER <br /> PROPERTY; LINE PRIVATE DOMESTIC WELL PUBLIC, DOMESTIC WELL <br /> INTENDED USE ! Ty E Of` TELL ,; ;CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable i.Tool- Dia..., of',Well. Excavation SrD- <br /> (� Domestic/private ' Drilled Dia. of'Well Casing fd <br /> Domestic/public ;"Driven Gauge of Casing / �-- <br /> Irrigation ..Gravel Pock . Dep.th 'oL.Grout Seal <br /> Cathodic Protection _X, Rotary Type` of Grout <br /> Disposal T Other Other 'I'iformation" <br /> Geophysical Surface Seal Installed By: <br /> PUMP-INSTALLATION: Contractor . 76e <br /> Type of Pump H.P. 3 <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 /> 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'constructi.on. 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--tie-we-1—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 ANDA FINAL INSPECTION. <br /> SIGNED TITLE -_- <br /> RA I LAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION. ACCEPTED. BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTION PHASE I/FI INSPECTION ' <br /> INSPECTION BY : DATE f <br /> . INSPECTION BY DATE <br /> '..E H 1426 Rev. 1-74 3/76 2M <br />