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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE; Y 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT PermitNo. �j P864� <br /> ` THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 8 a16-9J <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. `1862ooand the- Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �z ff NI L L� /2� ' �,� L CENSUS TRACT Z�f�- fs� o/ <br /> Owner'stName 't7g.� �'.� /�v�c.�. r Phone <br /> .S / 3S / <br /> Address 1G/ k//) Al � q,,/v c� - City O,v <br /> Contractor's Name Z w;�/10 Gf/E/� 1 ,& , L LicenseN_ X711 c�, Phoned _.. /„So <br /> i <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN /% RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALATION / / PUMP REPAIR/ 7 PUMP REPLACEMENT /-7 <br /> Other 17 C <br /> DISTANCE TO NEAREST: SEPTIC TANKSIJD a SEWER LINES — PIT PRIVY - N <br /> SEWAGE DISPOSAL ,FIELD — CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE'kf PRIVATE DOMESTIC WELL25UQ4PUBLIC DOMESTIC WELL R <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of,Well ExcavationZ yW <br /> _ Domestic/private Drilled Dia, of Well Casing /y <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 165 <br /> Gravel Pack Depth of Grout Seal " Ul/ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information Al+ S ,2u <br /> Geophysical Surface Seal Installed By: <br /> c[ <br /> PUMP INSTALLATION: Contractor IZt <br /> Type of Pump - H.P. <br /> i <br /> i <br /> PUMP REPLACEMENT: / / StatelWork Done <br /> PUMP REPAIR: /-7 State Work Done <br /> DESTRUCTION 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 District <br /> and the 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 n tify them before putting the well in use. The 'above <br /> information is true to th a of cnowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO NS <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHARE I <br /> A LCATION ACCEPTED BY ''(PAI' DATE s-26 27 <br /> AD TIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S / IN INSPECTI <br /> INSPECTION BY DATE INSPECTION BY ATE )71 <br /> I <br /> i <br /> E HV1426 Rev. 1-74tf17 . . <br />