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r Pte.- <br />+ SAN JOAQUIN LOCAL. HEALTH DIST ICT W-P& eg=- / <br /> FOEjEF ICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif.► /rJ/ /I�3,� <br /> Telephone: (209) 466-6781 <br /> r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued -47-7 <br /> (Complete In Triplicate) <br /> Application isiereb 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 /> Counti Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Dist4 ct. <br /> JOB ADDRESS/LOCATION SO,) � zr � /?� CENSUS TRACT <br /> � Isl...... /3 <br /> Owner's Name � E Phone <br /> i Address y SrCity <br /> Contractor's Name License �����/ Phone Y - lsz. <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_% RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK jCj�.fSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL IF SLD ' - CESSPOOL/SEFPAGE PIT OTHER W <br /> PROPERTY LINIVATE DOMESTIC WELL9&L3- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing � to <br /> Domestic/public Driven Gauge of Casing 1,4 4jz <br /> (p <br /> Irrigation Gravel Pack ~ Depth of Grout Seal ypr <br /> i Cathodic Protection Rotary f Type of "Grout --� <br /> Disposal Other Other Information -- <br /> f Geophysical Surface Seal Installed By: <br /> 4 <br /> PUMP INSTALLATION: Contractor �D LtGF,e•�5 �� 5 <br /> Type of Pump Rm ri H.P. '17-7l3f{P <br /> LA <br /> PUMP REPLACEMENT;• - <br /> r _ / / State. Work -bone'; <br /> PUMP .REPAIR: / / "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 a <br /> SWELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br />' information is true to the b o my k ledge and belief, <br /> PRIOR TO ANA FIN E i WILL CALL FOR A GROUT IN G T N <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY )2Wj&, DATE -?1 <br /> ADDITIONAL COMMENTS: <br />' PHASE II GROUT INSPECTI SE III/FINAL III/FINALINSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ff Afzm? <br /> W U l z qL tx 1 177 R 7M <br />