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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFIC& USE 1601_ E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -2-2-3?'F <br /> ' r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 and tte Rules and Regulations of the San Joaquin Local Health District. <br /> _ _t ? i <br /> JOB ADDRESS/LOCATION � 002 L. pRNli T LN. . ... CENSUS TRACT <br /> Owner's Name ELrnR G�1C�C"'�._ --_-- Phone <br /> Address <br /> � City ' :.LOD t <br /> Contractor's Name _ .License Phone_ Z,: <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /, RECONDITION /-7 DESTRUCTION /-7 <br /> ' PUMP INSTALLATION ILK PUMP REPAIR / / PUMP REPLACEMENT "'"'-7 <br /> —/ <br /> + Others <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAT.- FI_ELD CESSPOOL/SEEPAGE PIT ; OTHER <br /> PROPERTY LINE =c'PRIVAT$/DOMESTIC_WELL` ._P_UBLIC DOMESTIC WELL Q <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 1- Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal , <br /> I Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information e,. <br /> Geophysical Surface Seal Installed•"Byt- <br /> PUMP INSTALLATION: Contractor Go2.�lr <br /> Type of Pump -rNe-W W?=A► H.P. <br /> r <br /> 4 <br /> PUMP REPLACEMENT: / / State Work Done ` <br /> PUMP / / State Work Donef <br /> i <br /> DES-TRUCTION OF.WELL: Well-Diameter ^- �_ -- -�-- ' — "-- -Apprbximate Depth <br /> Describe Material and Procedure- <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health istrict <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 P T of the well and notify them before putting the-well in use. The above <br /> informatio a to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO R ANVA FINAL INSPECTION. <br /> SIGNED., TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> " FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTEb BY ,-•, DATE <br /> ADDITIONAL_ COMMENTS: r' <br /> °.:PHASE I.I GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY a. , �;., DATE INSPECTION BY DATE �6 <br /> E H 1426 Rev. 1-74 �f 7.7 2M; <br />