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tri to .. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> iOF.OFF • E USE: 1'1� 1601 E. Hazelton Ave, ; Stockton, Calif. <br /> Telephone: (209) 466-6781 �p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7-J7 P' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> . (Complete In Triplicate) p C-0 - 2_qo-10 <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulaiojisof the, SarJoaquin Local He lth Dis rict. <br /> JOB ADDRESS/LDCATION /A -, ,I _Ale CENSUS TRACT <br /> Owner's Name ' ,_ , - . moi �� Phone <br /> t <br /> Address - #" F city <br /> Contractor's Name. Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION /- <br /> _77PUMP INSTALLATION /, % PUMP REPAIR /_/ PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial, Cable Tool Dia, of We11 Excavation <br /> ^ Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation , Gravel Pack Depth of Grout` Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' ` <br /> Geophysical. Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractoras. r "- <br /> Type of Pump er/r �� r / _ H.P. <br /> PUMP REPLACEMENT: / / State Work Done' <br /> PUMP -. R: , /V./ State Work Done A--*0 <br /> DE TRUCTION OF WELL: Well Diameter Approximate, Depth <br /> Describe Material and -Procedure <br /> t <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 <br /> after completion of my work on a. new well, 'I will furnish the San Joaquin Local Health District <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 AND A FINAL INSPE GTION. <br /> SIGNED f f TITLE 2-A-a <br /> At (DRAW,PLOT PLAN ON. REVERSE SIDE) T'- <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I <br /> APPLICATION ACCEPTED BY DATE e <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PIL4,gE I/ NAL. INSPECTIO <br /> INSPECTION BY 44A DATE INSPECTION BY ATE 2 7 <br /> ell - T 7 "-/ <br /> 1/17 - 2M <br /> E H 1426 Rev. 1-74 - _ <br />