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JOAQUIN LOCAL HEALTH DISTRIC • i <br /> FOR OFF CE USE: 16C 'E. Hazelton Ave. , Stockton, Ca- /r✓ <br /> Telephone : (209) 466-6781 " <br /> nn PLICATION FOR WELL CONSTRUCTION OR PUMP PERT ermit No. <br /> Xte <br /> 7here <br /> HIS PERMIT EXPIRES 1 YEAR FRO?i DATE ISSUED Issued 'v- <br /> (Complete(Complete In Triplicate) <br /> pplication is made to the San Joaquin Local Health District for a permit to construct <br /> ad/or install the work herein described. This application is made in compliance with San Joaqui <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATION CENSUS TRACT <br /> wners Name £ 1� phone � ! 3195ti <br /> f � <br /> I Jdress 1 q City <br /> ontractor's Name i '�^ 6 r- <br /> �rli rl �Q License �qO�j"3Photse 5ysj <br /> YPE OF WORK (Check) : NEW WELL --T:DEEPEN / / RECO) IC?; / / DESTRUCTIONS] _ <br /> PUMP INSTALLATION / / PUMP REPIR / PUMP REPLACEMENT <br /> Other / / -- -------{ <br /> ISTANCE TO NEAREST: SEPTIC TANK aCG�_ SEWER LINES PIT PRIVY <br /> 2,E r <br /> £:PA.� <br /> SEWAGE DISPOSAL FIELD CES SPOOL�1��. E PIT OTHER <br /> PROPERTY LINE/ i r <br /> PRIVATE I)O.NIESTIC [, 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 /> ------------------ <br /> Irrigation Gravel Pack DeT)th of Grout Seal _ <br /> Cathodic Protection Rotary Type of Grout _ � <br /> Disposal Other Other Information i <br /> E, Geophysical Surface Seal _Installed _BY: - W <br /> UMP INSTALLATION: Contractor <br /> Type of Pump T H.P. <br /> PUMP REPLACEMENT: / / State Work Done _ -- <br /> PUMP .REPAIR: d / / State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> VV Describe Material and Procedure <br /> 0/d 40 el Ls -"n "j/' e 65 A �-r�.,,,f Cfl/ /��.� 'L;;..y <br /> hereby agree to comply with a l laws and eegul.ations of the San Joaquin Lo al Health District <br /> tnd the State of California pertaining to or regulating well-construction. Within FIFTEEN DAYS <br /> after completion of my work"on:: `' t w well, I will furnish the San Joaquin Local Health District z <br /> TELL DRILLERS REPORT of the well and notify them before putting the well in use. The above i <br /> _nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROAT INSPECTION <br /> RIOR TO GROUTING AND A FINAL INSPECTION. <br /> ;IGNED TITLE gLl1�` <br /> (DUW POT PLAN ON REVERSE SIDE) - <br /> '� FOR DEPARTME`:T USE ONLY <br /> 'RASE I 2-/�/,7 <br /> APPLICATION A'CCE-PIED <br /> ,BY DATE <br /> ',DDITIONAL COMMENTS: - d <br /> PHASE ,II GROUT INSPE0TION PHASE III(F;NAL I48PECTION <br /> CNSPECTION BY^ DATE , INSPECTION BY DAAT�E, � <br /> E H 1426 Rev. - I-74 . <br />