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AN JOAQUIN LOCAL HEALTH DISTRI - <br /> f FOF� OFFICE USE; It, <br /> f E. Hazelton Ave. , Stockton, CL_j. <br /> Telephone: (209) 466-6.781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 17 <br /> THIS PERMIT EXPIRES IYEAR' k'RQM DATE ISSUED Date Issued <br /> (Complete :Ttt 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 Joaquit <br /> County Ordinance No. 1862 and the Rut and- Regulations of ' he San Joaquin Local Health District. <br /> - <br /> JOB ADDRESS/LOCA I �f�/off CENSUS TRACT <br /> Owner's Name DLYyJ <br /> Phone j <br /> Address <br /> Contractor's Name License J4a-3721 Phone4l&%r <br /> TYPE OF WORK (Check): NEW WELL DEEPEN -/_7 RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: ,`SEPTIC TAN �'-y— SEWER LI <br /> NE5 FIT PRIVY <br /> i <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 7 25 <br /> Domestic/public Driven Gauge of Casing Q <br /> t/ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Prosection Rotary Type of Grout _ 12dryclxrl_ 9` <br /> Disposal Other Other Information ---- <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor -�Zk Tj9 JL- S <br /> Type of Pump H.P. _! c� -.- <br /> PUMP REPLACEMENT: /t/ State Work Done <br /> ?LW__, /_% State Work Done <br /> 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 Joaq in 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 notify them before putting.. the- well in use.. The above <br /> information is true to the-best-of- my knowledge and belief. I WILL GALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSETLE SIDE) KiAl <br /> k <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> _;1,)144461i- DATE 1;9 .1-7-t <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHASE /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE ?-Z±: 7s`"�� <br /> alel <br /> t E H 1426 Rev. 1-74 1-74 2M <br />