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A w SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH 0FFICE.„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 42 J13�7 1 <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 +r� <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District'. <br /> JOB ADDRESS/LOCATION ner Rol.SIAM''i2So• 0-� Hwy (W- �as�-�i so TRACTS " <br /> i <br /> Owner's Name Phone 5221?_ � <br /> Address S. Wha ner�^ City E5[(,L 6]"L <br /> f <br /> Contractor's Name �, i1 .a• License # �Phone <br /> i <br /> 4 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION / / 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 CE POOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ` <br /> X Domestic/private Drilled Dia. of Well Casing L " <br /> Domestic/public -� Driven Gauge of Casing I(aQ �'. <br /> Irrigation Gravel Pack Depth of Grout. Seal <br /> Cathodic Protection _ Rotary Type of Grout _Ben :Q n , tc, <br /> Disposal Other Other Information 154/3-j, h„ ty ) h �( `# <br /> Geophysical Surface Seal Installed By:_ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 5 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / <br /> _ State Work Done w knJ o o AlN�n � D rN <br /> DESTRUCTION OF WELL: Well Diameter ; Approximate DepthyN1[ <br /> Describe Material and Procedure 1 <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 'completion <br /> 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 FINAL -INSPECTION. <br /> SIGNED _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I J 2 1 Z-_'7� <br /> APPLICATION ACCEPTED BY DA <br /> ADDITIONAL COMMENTS: <br /> PHASE AI GRO T INSPECTION PHASE III/FINAL INSPECTION r <br /> INSPECTION BY DATE f 2 / INSPECTION BY DATE �Z,1z �7 7 <br />