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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> It,01 E. Hazelton Ave. , Stockton, Calif. II <br /> Telephone: (209) 4b6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> T THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /0'17-7,7 <br /> (Complete In Triplicate) <br /> .1ppllcation fs h",ro y rade to the San Joaquin Local Health District for a permit to construct <br /> .11111/or Install the work herein described. This application is made in compliance with San Joaquin <br /> C..nnty Ordinance No. 1862 and the Rules and Re ulations of the San Joaquin Local Health District. <br /> .1011 ADDRESS/LOCATIONj—�f G /_ /= •%�, 1C.= TjE - '; � nl , CENSUS TRACT <br /> Owner's Name Phone �i <br /> Address / ✓ [ 171j����!�L�2-a.Z City �;e'16 <br /> ,T <br /> Contractor's Name ,%�'✓,'" �!/ ���- -j�- License Phone, <br /> TYPE OF WORK 1"heck) : NEW WELL /Cj- uEEPEN /7 RECONDITION /7 DESTRUCTION /7 _ <br /> PUMP INSTALLATION /i4-�7FUMP REPAIR / / PUMP REPLACEMENT / I <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 DOMESTIC WELL �C <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C. <br /> Industrial Cable Tool Dia. of Well Excavation <br /> [--'lfinestic/private Drilled Dia. of Well Casing R <br /> _ Domestic/public Driven Gauge of Casing /,S U <br /> _ Irrigation Gravel Pack Depth of Grout Seal S'c� <br /> Cathodic Protection _(C Rotary Type of Grout <br /> Disposal Other Other Information �\ <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor -->. l r \ <br /> Type of Pump aeJ4- <br /> PUMP REPLACEMENT: / / State Work Done ` <br /> PUMP REPAIR: / / state Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to cumply with all laws and regulations of the San Joaquin Local Health District <br /> and the Stata of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will ft, 'aish the San Joaquin Local Health District a <br /> WELL DRILLERS DEPORT of the well and notify them brrire putting the well in use. The above <br /> information is true to the beat of my knowledge Ano belief. I WILL CALL FOR A GROUP INSPECTION <br /> _PRIOR TO GROly1'ING AND A FINAI. INSPECTION. <br /> SIGNED /IZ/ TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ��J `2 �:--+��'1 PATE <br /> ,1DDLTIONAL COMMENTS: <br /> P1L1SF. 11 GROUT INSPECTION PHASE I I/FINAL INSPECTION i <br /> 1N;;PCCTION by _ DATE - - INSPECTION BYA�_ DATE �=L?� <br /> // ` <br /> � /et-4) 1177 _ 24 <br />