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C0 �� 1 � SAN JOAQUIN LOCAL 'HEALTH DISTRICT <br /> FOR 0 FICE USE: /'/ 1601 E. Hazelton Ave. , Stockton, Calif, <br /> VVVVV 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,-;:�Sl <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/ y-o �y�- I-r4(hk r/.�"� `� r¢a 9F CENSUS TRACT L' E Z3D-Dy <br /> Owner's Name �. Oran �o@ i-� a��f �J Phone <br /> / <br /> Address 0 lajoy� `7� City <f,4, �rn� <br /> Contractor's Name License d !f 3 ZW Phone <br /> I <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP�REPAIR PUMP REPLACEMENT <br /> Other <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 DOMES <br /> OMTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> - Industrial Cable Tool Dia. of Well Excavation 4 <br /> Domestic/private Drilled IDia. of Well Casing + <br /> Domestic/public Driven Gauge of Casing <br /> -° <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical // Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump „r00in H.P. .0 (� 1 <br /> PUMP REPLACEMENT: /'V/ State Work Done 26,bltca howb 'tt�iX <br /> PUMP .REPAIR: /-7 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 /> WELL DRILLERS REPORT of the well and notify them before putting- the-well in use.. The above <br /> information is true to the best ofmy ;leaeelief. I WILL CALL FOR GROUT INSPECTION <br /> PRIOR TO ING AND A FINAL INSPE <br /> SIGNED <br /> D ' W PLOT PLAN ON RE SE SID _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASINSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE -/> <br /> i <br /> � + E H 1426 Rev. 1-74 - 1_74 2M <br />