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E folf / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi.OFFICE USE: F !/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 26 ' SG70" <br /> 3 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Issued 2. f "=7 <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 /> JOB ADDRESS/LOCATION �'L !� /Z /,� CENSUS TRACT <br /> Owner's Name L Phone ' 3 S C 5:� <br /> Address EL 3 3-e_- E`L 3lE 2. <br /> City ' CA Af PO c h LIP <br /> Contractor$'s Name Ad 7- E9QSS' !��[,�.p1?tLL License d Phone <br /> � f��_... . . ��,�� X4,5` <br /> t � <br /> { <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN •/" RECONDITIONf% DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR'/? PUMP REPLACEMENT /7 <br /> Other %/ -- <br /> DISTANCE TO NEAREST: SEPTIC:TANK /67-0 SEWER LINESPIT PRIVY <br /> SEWAGE;DISP05AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 4 <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL � <br /> I INTENDED USE 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _�— Industrial _� Cable Tool Dia. of Well Excavation <br />;. X Domestic/private Drilled _ Dia. of�WellECasing= �. <br /> > _sr ,j C <br /> Domestic/public Driven Gauge of Casing /@2. <br /> Irrigation Gravel Pack Depth of Grout Sealr 0 ' \ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other'"; Other Information <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor, <br /> Type .of Pump _ H.P. 3 <br /> PUMP REPLACEMENT: , / / State Work, Done ' <br /> -PUMP '-REPAIR: <br /> . / / State Work Done <br /> DESTRUCTION OF WELL: F Well`Diameter " <br /> 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;anew wel'1', I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the yell .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 /> PLOT PLAN ON REVERSE SIDowl <br /> FOR DEPARTMENT USE ONLY <br /> 'PHASE.4. <br /> 'APPLICATION ACCEPTED BY e Y DATE, - <br /> AbDITYONAL CUMMENTS:TM € <br /> PHASE II GROUT INSPECTION PHASE III/FINAL III/FINALINSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 r' 1.1,7 If nu <br />