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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />"a F0 ;UFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.fid'_ 3631'0 <br /> THIS PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED Date Issued 5=/ -74. <br /> (Complete In Triplicate), <br /> Appiicmition'is hereby made the' 'San Joaquin Local, health District. for a permit to construct <br /> and/or install the work herein described. This applicationsis .made in compliance with San Joaquin` <br /> County Ordinance'No. 1862 and the Rules and Regulations of .the-San Joaquin Local Health District.. 1 <br /> JOB ADDRESS/LOCATION - r/t S' A t." 4 C SUS TRACT <br /> Owner''s Name • Phone .$- 7 701 <br /> . �....�� City <br /> Address <br /> License,C2 14,01.0 Phone. 53s�?o' <br /> Contractor s Name <br /> o� - -------� <br /> TYPE OF WORK (Check): NEW WELL /? DEE <br /> PEN RECONDITION I? DESTRUCTION /-7PUMP INSTALLATION I / PUMP REPAIR'/ PUMP REPLACEMENT <br /> Otherl / / + <br /> DISTANCE TO NEAREST: SEPTIC.,TANK SEWER LINES PIT PRIVY <br /> mm <br /> _�SEWAGEIDISPOSAL- FIELD. -•�--- �--`-CESSPOOL/SEEPAGE--PITOTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL \ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. of Well Excavation i <br /> Domestic/private Drilled Dia. of Well. Casing <br /> { Domestic/public Driven""" Gauge` of Casing <br /> 1 Irrigation Gravel Pack Depth of Grout Seal } <br /> Cathodic-Protection Rotary Type of Grout <br /> F Disposal i� ` Other Other Information <br /> Geophysical �..- r , Surface Seal Ins <br /> Geophysical <br /> PUMP INSTALLATION: Contractor <br /> -- . u <br /> .Type of Pump:. _H.P. <br /> 3 , <br /> f PUMP REPLACEMENT: / State Work Done <br /> PUMP .REPAIR a '- .. ~��-"State Work Done E <br /> DES1-RUCTION--.OP WELL:—Well,Diameter � Approximate Depth <br /> Describe -Material and Procedure - . <br /> f .I hereby agree to.comply with all laws and regulations of-tile $an'';?o`aquin Local Health District <br /> and the State of California pertainin,g% to .or regul.ating,well`construcCion. (Within FIFTEEN DAYS <br /> after completion of my work on anew 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING'AN A FINAL INSPECTION. <br /> S IGNEI} TITLE _74 T <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> F09 MENT U§§ ONLY <br /> PHASE 4:.I,. � <br /> APPLICATION' ACCEPT 6ZfVOT'I DATE s` <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT: INSPECTION P IN PE <br /> INSPECTION BY DATE INSPECTION DATE <br /> _ <br /> hZ75 2M <br /> A`H' 1676 itov_ 7..74 -- - <br />