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V JOAQUIN LOCAL HEALTH DISTRIC- <br /> FOE OFFICE USE: 16�. Hazelton Ave. , ,Stockton, Calve. <br /> S <br /> . <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. p-150- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/a s7 <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 <br /> County Ordinance No. 1862 a d t e Rules and Regulations of the San Joa uin Local Health District. <br /> JOB ADDRESS/LOCATIO O {'/ CENSUS TRACT <br /> c- <br /> Owner's Name �i�y._�Qin✓p - � f�) ��yt��� ,� Phone <br /> Address 3�D f � �i Gmfy4 f7t c�.LT CityjW/ <br /> Contractor's Name �� C X� (.Ac �� License ll��ba�� Phone D <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN /_/ RECONDITION /-7 DESTRUCTION /- <br /> PUMP INS ALLATI PUMP REPAIR / / PUMP REPLACEMENT, <br /> Other / / 4Y�-t7 <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 <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 Q <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical // S.ur�face Seal Installed By: <br /> PUMP INSTALLATION: Contractor 6220 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameters Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> -T <br /> and the State of California pertaining to or regulating well construction. Within FIFTEENDAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well 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 G UTING t FINAL INSPECTION. <br /> SIGNED , { �P TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEa r <br /> 1DDITIONAL COMMENTS: <br /> 7 7 <br /> PHASE II GROUT INSPECTION PHASE IU/FINAL INSPECTIOmy <br /> 'PECTION BY DATE INSPECTION BY DATE 10 Z-S- <br /> if <br /> it 1426 Rev. 1-74 • 1/77 <br />