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_ SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> `�"� Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.2 . —//K70 <br /> © 5 THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued U '� 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 2 2.19 9 AJC JR n 1z D <br /> CENSUS TRACT <br /> Owner's Name a u S Phone /I <br /> t <br /> City 4e Q 01 { <br /> Address c/ AJ . JR 11 <br /> Contractor's Name San Joaquin dump Co. License # 637 Phone j / <br /> .. - f e 1 <br /> TYPE OF WORK (Check) -. NEW "TEN / / RECONDITION DESTRUCTION`/_T- Pte" ` _ .. "_.. . <br /> PUMP INSTALLATION /[•7P� REPAIR / / PUMP REPLACEMENT /? <br /> AL <br /> Other /-7 <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 <br /> Domestic/private Drilled Dia. of Well Casing_ *: <br /> Domestic/public Driven Gauge of Casing- — � <br /> 'Irrigation u Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout Y <br /> Disposal Other Other`Information ' <br /> Geophysical Surface Seal Installed B <br />! PUMP INSTALLATION: Contractor .*-J i:!j <br /> H.P. <br /> Type of Pump 2 �f✓ - <br /> PUMP REPLACEMENT: / / <br /> State Work Done <br /> PUMP ,REPAIR T / / 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 District <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 <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 INSPECTION <br /> PRIOR TO GROUTIN A FINAL INSPECTION. <br /> SIGNED TITLE �nan�in ,,. l <br /> D PL T' PLAN 'ON RE FRSE SIDE �.; % of^Sa `o ain s hur <br /> FOR DEPARTMENT USE ONLY St. <br /> S2Q <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION LASE /FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION DATE <br /> 3/76 2M <br /> R M 1L96 RPu- 1-74 <br />