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s <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOArOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-5'-So 5 hol + <br /> k.i <br /> THIS PERMIT g2 IUS .1 YEAR FROM DATE ISSUED Date Issued , a �• *7 S <br /> i (Complete In Triplicate) <br /> .Application is hereby made to the San Joaquin Local ;Health District for a permit to construct i <br /> and/or install the work herein described. This application is :Wade in compliance with San Joaquin <br /> County Ordinance No. 1852 and -the Rules and Regulations of the ,San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> �Ile+a �_Slc 3 I <br /> Owner's Name All el"APhone <br /> i <br /> Address _3 S. City <br /> Contractor's` Name ZaB License" `_7 f Phone <br /> ...TYPE OF WORK; (Check)s• ANEW WELL �EEPEN /7 RECONDITION /7 f <br /> DESTRUCTION /"7 <br /> PUMP INSTALLATION L� PUMP ..REPAIR /� PUMP REPLACEMENT /7-, -ter <br /> ' -'.Other /7 <br /> ,DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE. DISPOSAL FIELD - , CESSPOOL*/SEEPAGE}PIT OTHER f <br /> j PROPERTY':LINE•.= PRIVATE DOMESTIC-WELL,: C, '. <br /> PUBLIC DOMESTIC WELL 4 I <br /> INTENDED USE'' - TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Ipdustrial Cable-1661 Dia. of Well Excavation <br /> 71- omestic/private .'': Drilled Di'a:.-of<• Weld Casin S <br /> g _ <br /> Domestic/public. Driven Gauge of`Casing <br /> �rrigation '' �ravel Pack ` Depth of Grout Seal <br /> Cathodic Protection- tary Type of ;Grout 6-6rn <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: Z)ge41Fj0 <br /> PUMP INSTALLATION: : Contractor ` <br /> _ Type of Pump H.P. <br /> `PUMP REPLACEMENT: <br /> State Work Done <br /> _ h <br /> PUMPIREPAIR: , L7 State Work Done <br /> ESIRUCTION..OF WELLa Well Diameter <br /> . Approximate Depth ,l <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 is <br /> WELL DRILLERS REPORT of the well and notify them before putting. the. well inn-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 r TITLE ; <br /> DRAW PLOT PMLON REVERSE SIDE <br /> PHASE-i <br /> FOR DEPAR MENT_ USE- ONLY.? <br /> APPLICATION-ACCEPTED BY `DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE VGROUT INSPECTION AFINAL INSPECTION <br /> INSPECTION BY DATE /1- /k- INSPECTION BY DATE �7J­ <br /> w lip <br /> � E H 1426' Rev. 1-14 F � 1-74 2M i <br />