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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO'_ OFFICE USE: ' 1601_ E. Hazelton Ave ,Stockton, Calif. <br /> ty ' Tele hone:P (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDDate Issued 7,7-Sy�3p <br /> (Complete In Triplicate) -77 <br /> Application is Aereby 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/LOCATION <br /> CENSUS TRACT <br /> Owner's Name ' <br /> i' <br /> Phoney �b-3 <br /> Address CW,6-- <br /> A,1 �� City ' <br /> Contractor's Name ALS-0 { <br /> �" S License #I Phone 7 <br /> z <br /> TYPE OF WORK (Check) : NEW WELL / - DEEPEN/ RECONDIT N / / DESTRUCTION /_7 <br /> PUMP INSTALLATION � PUMP REPAIF PUMP REPLACEMENT- 1-7 <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 v <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> _. <br />_ _Domestic/public Driven Gauge of Casing <br /> Irrigation ® � - •� <br /> Gravel Pack - Depth of Grout Seal <br /> Cathodic Protection _ / Rotary Type of Grout <br /> Disposal <br /> Other Other Information . <br /> Geophysical Surface Seal Installed By: <br />'UMP INSTALLATION: Contractor. <br /> 17 A/ <br /> Type of Pump H.P. <br />'UMP REPLACEMENT: <br /> State Work Done- <br />'UMP REPAIR: <br /> one'UMP '.REPAIR: 77 State Work Done <br /> GvGG- o� 00vl+-r� <br /> ES:TRUCTION OF.WE •L ` Werl 45Rme <br /> ........_ Appr-oximat-*Depth'- f' . /9 <br /> fl Describe .Material and Procedure <br /> hereby agree to comply with-all laws and regulations of the San Joaquin Local Health District <br /> nd the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS [ <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> reformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 3IOR TO G UTING AND FI AL INSPECTION. <br /> IGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE S E <br /> MASE I FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY DATE <br /> 7 --�I-77 , <br />)DITIONAL COMMENTS: "" .__ °. -- •�,_ - <br /> PHASE IJUROUY INSPECTIO PHASE IFINAle INSPECTI N <br /> VSPECTION BY DATE 7 INSPECTION BYPO ATE Z7' <br /> E H 1426 Rev. 1-7G 7-7 <br />