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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ._ ';_�F- OFFICE USE: 1601 E. Hazelton Ave. Stockton Calif. <br /> Telephone: (2094) 466-6781 <br /> + APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�_, <br /> zfl <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -_-9-,,1--29 <br /> (Complete In Triplicate) <br /> Application is hereby made t 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 />' JOE ADDRESS/4&GAZLQji� -- CENSUS TRACT ' <br /> Owner's Name �! Phone <br /> Address <br /> city _ <br /> 3 <br /> Contractor's Name <br /> sa.cense �� Phone <br /> t <br /> TYPE OF WORK (Check) : NEW WELL % DEEPEN /_/t RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATIONf PUi��P REPAIR. / / PUMP REPLACEMENT /-7 <br /> Other 1/ <br /> ` / , <br /> DISTANCE-TO NEAREST: SEPTIC TANK _,,fSEWER LINES IT PRIVY Q <br /> { SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE PIT �BJ IV-OTHER Vy <br /> PROPERTY LINRIVATE DOMESTIC WELLZ-42,t PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS CA <br /> Industrial tCable Tool Dia, of Well Excavation C <br /> Domestic/private I Drilled Dia. of W611 Casing di �� `— <br /> Domestic/public ? Driven Gauge of Casing /Z <br /> Irrigation Gravel Pack Depth of Grout Seal -f- <br /> Cathodic Protection =-7°' Rotary Type of Grout . <br /> Disposal ? Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: .� <br /> Contractor <br /> Type o�f Pump r H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: <br /> / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter s _ Approximate Depth <br /> -----.-De-scrib-e--Material—and-�,Prece-aure - <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 wolf "construction. _Within FIFTEEN DAYS <br /> after completion- of-my.,wor-k on-a-.new well-,-I-.wil1 furnish the -San Joaquin Loca1 Health District a <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 GROUTING AND A FINALfINSPECTI <br /> SIGNED TITLE ? <br /> € �FffiRDE <br /> P REV RSE SIDE} <br /> ARTMENT USE ONLY <br /> PHASE T — 00, <br /> APPLICATION ACCEPTED BY ,,C DATE �:,�Z-7;Zl _� j <br /> ADDITIONAL COMMENTS: € <br /> P E IT GROUT INSPECTION PHAS III/ INAL TNSPECTION <br /> INSPECTION BY DATE /� INSPECTION EY DATE <br /> E H 1426 RPV- , 1-7G 9M <br />