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SAN JOAQUIN .LOCAL HEALTH DISTRICT <br /> FOS,;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I (Complete In Triplicate) <br /> Applicationis 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 N6. '1862 and the Rules and Regulations of the -San Joaquin.1oca1 Health District. <br /> JOB ADDRESS/LOCATION O 1_� :2 S L. '-CENSUS TRACT <br /> ' CATV ` ,. k39s- �( ft <br /> Owner a Dame Phone' <br /> Address lzq,o , ; S T, N Rd. = �,7 City,- zsc ig to A", r <br /> Contractor's Name :D, S ,� �..1-. License &279p/c� Phonetic <br /> TYPE OF WORK (Check): NEW WELL i7 DEEPEN ,/7 RECONDITION /7 -DESTRUCTION f7 <br /> PUMP INSTALLATION -/-7 PUMP REPAIR' PUMP REPLACEMENT %T <br /> Other-/ / — <br /> DISTANCE TO NEA LEST:_SEPTIC 7 TANKS V SEWER LINES,,.f PIT PRIVY <br /> -� S•iWAGE�DISPOSAL FIELDCE5SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ; CONSTRUCTION SPECIFICATIONS <br /> „ <br /> Indus-trial Cable Tool Dia. of We11 Excavation <br /> Domestic/private _t_.._.._ Drilled s Dia. of Well Casink2 a .. <br /> Domestic/ dblic `.- <br /> P _ Driven -� +t'--Gauge`of Casing: - r� <br /> Irrigation -kzz,.,'Gravel Pack - Depthof-Grout-ftal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal - �- Other, -i Other Information r� <br /> Geophysi`6a1," <br /> Surface Seal Installed Z: <br /> PUMP INSTALLATION: Contractor ; <br /> TYP6` .o7f Pump H.P. <br /> ,PUMP REPLACEMENT: .: / / - State Work Donee <br /> PUMP 'REPAIR.: ; / .State Work Done <br /> S2ES1RUCTION OF '•WELL: Well -Diameter Approximate Depth <br /> g 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 Californiapertaining 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 /> '.WELL DRILLERS .REPORT of�athe.-ve11.-and-no.ti-fy-them before ut'ting.the..' wel:I:in:use-.:. "The—above <br /> information is true to the,best-of my knowledge and belief. I WILL GALL FOR,X GROUT INSPECTION <br /> PRIOR TO GROUTING ANDi' FINAL' INSPECTION. <br /> ,,SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOEPARTHEXT USE ONLY <br /> `PHASE I <br /> i4PPLICATION ACCE D 'BY1k,rX017 /�I L A10T DATE, .S-IO 7� <br /> ADDITIONAL COH MENTS; "'— <br /> PHASE II GROUT -INSPECTION 'PHASE III' INAL INSPECTION <br /> :INSPECTION BY .DATE ,INSPECTION BY ATE <br /> .:, . <br /> E H 1426 Rev. i-ii r. - f./ter �,u <br />