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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> + FOp.OFF10E USE: 1601 E. Hazelton: Ave. , Stockton, Calif. <br /> e Telephone : (209) 466-6781 <br /> 4 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / '. 7® <br /> q.. (Complete In Triplicate) <br /> Application isshereby „madeto the San Joaquin Local Health: District for a permit to construct <br /> and/or install thework herein described. This application is made in compliance with San Joaqui <br /> County Ordinance'.No. 1862 and the- Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT - • <br /> p. DIU <br /> Owner's Name 1A I <br /> k <br /> Phone (� <br /> { Address + . - , <br /> City <br /> Contractor's Name A1�� <br /> C : s s License �"'Phone <br /> I <br /> TYPE OFA WORK. (Check) : NEW WELL <br /> 22T DEEPEN / / RECONDITION /_/ DESTRUCTION /_ N <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 N <br /> Other / / ' <br /> f DISTANCE TO NEAREST: SEPTIC`TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Dpi <br /> ' PROPERfiY"EINE`= P-Rl7ATE`DOMESTIC-WEI<r""""'""'p 1C j��MESTIC WELL <br /> INTENDED 'USE TYPE OF WELL <br /> Industrial ; 4 . :�CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation <br /> DomI-eestic/private--_.,,.,,,,,, Drilled Dia, of Well Casing <br /> R Domestic/public "Driven <br /> Irrigation Gauge of Casing <br /> Gravel ;Pack t" Depth of Grout Seal <br /> Cathodic P_r_otection Rotas`� ' <br /> Disposal y �. ti• TYPeof_.Grout <br /> p Other , f_ O'thett Information <br /> Geophyszca.1$ '' <br /> Surfa , Seal Installed By: <br /> a- <br /> PUMP INSTALI;ATION Contr_ac.tor- ,, <br /> Type of Pumpi � <br /> H.P. <br /> PUMP REPLACEMENT <br /> State Workx6ona <br /> PUMPf�EPAIR: i"s /!_/ State Work Done <br /> .RE ST CT10N QF WELL: Wei 1 Diameter <br /> Describe Material and Procedure Approximate Depth <br /> Thereby agree to comply with all-laws and regulations of the San Joaquin Local Health District <br /> and the State,,of Califordia 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 thewell 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED' - <br /> TITLE r <br /> v. <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASEI " FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �i✓� DATE/� ,, <br /> ADDITIONAL COMMENTS: �^ <br /> PHASE II GROUT INSPECTION PHAS /FIN INSPECTION <br /> INSPECTION BYi+ DATE INSPECTION BY <br /> ATE _ L - <br />,. E H 1426 LRev. 1-74 ..__. _.. '� �� 0i 77 7�ur <br />