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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ` <br /> Telephone: (209) 466 -678 . _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. yS y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3�� <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/LOCATION4 <br /> rel. Mo.ale,.,y/1, Re cENsus TRACT � <br /> I <br /> Owner's Name ft44e. Phone Qf7f" <br /> Address City <br /> 1 <br /> Contractor s Name klcjl<V �_An ,� License # 774 Phone <br /> TYPE OF WORK (Check) : NEW WELL / r DEEPEN / / RECONDITION / / DESTRUCTION /7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / —PUMP PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK P Z.c3 �. SEWER LINES PIT PRIVY d <br /> SEWAGE DISPOSAL ,.FIELD g_2* ' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE )'PRIVATE DOMESTIC WF.LL'� PUBLIC DOMESTIC WELL -j <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /y _ <br /> _ Domestic/private Drilled Dia, of Well Casing bee <br /> Domestic/public - Driven Gauge of Casing 1�� pg� pyo <br /> Irrigation ` Gravel Pack Depth of Grout Seal �ee. , <br /> Cathodic Protection - Rotary Type of Grout r-p� <br /> Disposal Other-:- Other Information <br /> Geophysical N y _ Surface Seal Installed B :d/clrF me.e- aul/j <br /> PUMP INSTALLATION: Contractor D o , <br /> Type of Pump <br /> 4°' —:r ., <br /> . 6b.4- +/�.te. _ H.P. _1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter t Approximate Depth <br />--�• <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 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 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 INSPEC'T'ION. <br /> SIGNED TITLE <br /> lez (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <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 DATE4 <br /> E H 1426 Rev- 1-74 6/77 _ 2M <br />