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� '1' JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 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 7 2F7Gf <br /> (Complete In Triplicate) <br /> kpplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ind/or install the work herein described. This application is made in compliance with San Joaquir <br /> ,ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �aS6 {�� NJfJ�V7ll I)L� CENSUS TRACT <br /> haner's Name <br /> ss yes E_760:� (5 //V C__ Phone <br /> �o`-��.� J , Phone �,fd <br /> lddress f��l � <br /> City <br /> :ontractor's Name Zsj-l9 /"-jMp;' S O License #A_y 73Phon4A g.'�-X)/ <br /> TPE OF WORK (Check) : NEW WELL /7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION _ PUMP REPAIR /% PUMP REPLACEMENT <br /> Other <br /> )ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY (rI <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �Q <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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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 /> UMP INSTALLATION: Contractor /0.7_17p <br /> Type of Pump '7-y x/37 ri. H.P. <br /> UMP REPLACEMENT: / / State Work Done,100j-0- 0U7- -7s- ( <br /> UMP .REPAIR: /% State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ad the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> iter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> tIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNED ,�. „ <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> SASE I FOR DEPARTMENT USE ONLY <br /> 'PLICATION ACCEPTED BY B / �n ^ DATE <br /> )DITIONAL COMMENTS: / <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE , /_ 2V <br /> E H 1426 Rev. 1-74 1-74 2M <br />