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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> TOT,-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L- 34i <br /> I -a- �b <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 the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION T'GN/,✓S 2✓��a L'T C.[-'vTG�Q CENSUS TRACT <br /> Owner's N 4,T, <br /> Name � 21AI 1 — _ - Phone <br /> Address 2p A/' L o 1> =/ A 1//- . <br /> - <br /> Contractor's Name (D GI/ar License # Phone <br /> TYPE OF WORK (Check) : NEW WELL J-7 DEEPEN -/7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION %/ PUMP REPAIR ,/-7-pump REPLACEMENT /7 <br /> Other L-1 . . . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> _ PROPERTY LINE -- PRIVATE DOMESTIC WELT, 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/publicDriven Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout Seal. � <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Informations <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: <br /> �„•�, Contractor <br /> Type of Pump H.P. <br /> e <br /> PUMP REPLACEMENT / / State Work Done <br /> PMS IR: / / State Work Done 3 <br /> DES-TRUCTION OFWxLL: Well Diameter /z Approximate Depth 2-0 <br /> Describe Material a d 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 a <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 notifythem before j <br /> putting.. the .well in.use.... The above <br /> information is true to the-best.of my knowledge and belief. I WILLCA&L FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINALSPE ION <br /> SIGNED _ TITLE <br /> -MRA <br /> W LOT PLANON REVERSE SI I <br /> FOR DEPARTMENT USE ONLY 1 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ,o,,, <br /> E H 1426 Rev. 1-74 -- - 4/75 2M <br />