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b . ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 3 <br /> Telephone: (209) 4.66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 - 41 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6-y- <br /> ( <br /> (Complete In Triplicate) <br /> Application is hereby made t� 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 LJe%•Vi ti c-�, 4 K a: CENSUS TRACT <br /> Owner's Name Phone 2'49 301-7 <br /> Address 2 City a <br /> Contractor's Name a� ` o Licen a # � Phon 59 S" <br /> ^Tr'- <br />-TYPE 0Fk-WdRK"'(Chec�) —NEW WELL / / W DEEP RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION 'S PUMP REPAIR '/—/7-PUMP REPLACEMENT / i <br /> Otherj�no 071 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ` <br /> w SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OCHER <br /> PROPERTY. LINE .. PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial it Cable Tool Dia. of. Well Excavation 4\ <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public : Driven Gauge of Casing <br /> Irrigation . Gravel Pack Depth of Grout Seal t <br /> Cathodic,Protection Rotary Type of Grout F <br /> Disposal . Other Other Information <br /> Geophysical Surface Seal Installed 'By: <br /> PUMP INSTALLATION: Contractor <br /> Type oJfL Pump TLk c bx& H.P. <br /> -Z D <br /> PUMP REPLACEMENT / / State Work Done i <br /> FUMP ,REPAIR: /% State Work Done <br /> wDESTRUCTION OF WELL: 'Well DiameterApproximate 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 regulatirig well "construction. Within FIFTEEN DAYS <br /> after completion of my work on a neva 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 true to-the best o my.. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GO-IXNGIANDAFINAL I ECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTEDBY DATE '� I <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIOK PHASE II FINAL INSPECTION <br /> INSPECTION BY <br /> DATE INSPECTION BY DATE <br /> E H 1426 'Rev. 1-71A !x/75 2M � <br />