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�o oy( W e -/ /� SAN JOAQVIN LOCAL HEALTH 01STR1Cp <br /> F06 OFFICE USE: / 1607. E. Hazelton Ave. , Stockton, Calif. <br /> VVV Telephone: (209) 466-5781 <br /> APPLICATION FOR WELL CONSTRUCTION Oit PUMP PERMIT Permit No. <br /> T <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .5-�-%5- <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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �p /�t C j gy h� r+ �,� os. lame 146 CENSUS TRACT <br /> Owner's Name 'j� fJ� f� g dr e?, Phone <br /> Address O, �J D �' /(j d'" � <br /> City c��C/� 741a <br /> Contractor's Name c���a�� � j License 11 &37J1-­Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR �/ PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL T 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 /> _ CZ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout (1� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contracto- <br /> Type of Pump H.P. t�L iiistrict- <br /> and <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /4C/ State Work Done)ES•TRUCTION 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 Dthe 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 bes my k w edge aa)ao belief. I WILL CALL FOR A GROUT INSPECTION <br /> 'RIOR O TING AND A FINAL E IO . I \ <br /> 3IGNE .,q ,i <br /> '>zTLE <br /> ( PLOT LAN ON REVtkSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> 'HASE I <br /> APPLICATION ACCEPTED BY <br /> DATE S — <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR S ECTIONPHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY tDATE - <br /> E H 1426 Rev. 1-74 C163, — <br />