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A P/ SAN JOAQUIN LOCAL.11EALTH DISTRICT <br /> FOB!OFFICE USE: Calif.- 160i E. Hazelton Ave, , Stockton, al � <br /> Telephone; (209)\466-6751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued j <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/ tY w. - &40e) S� G CENSUS TRACT <br /> Owner°s Name t� l i �{- Phone + <br /> Address atk 40""'" � c,_ City k �--� <br /> .. o2o Kt 1�. <br /> Contractorrs Name I� Le-t, S License �Phone <br /> 1 . <br /> TYPE OF WORK (Check): NEW WELL .0 DEEPEN 17 RECONDITION /_7 DESTRUCTION '/_7- <br /> PUMP INSTALLATION S PUMP REPAIR /-7 PUMP REPLACEMENT. ,f7:Y - I _ I <br /> Other <br /> )DISTANCE TO NEAREST: SEPTIC TANK - Q SEWER LINESPIT PRIVY "�-7 /ya <br /> SEWAGE DISPOSAL FIELD �'� �sEEPAGE PfT !2.ID`f-OTHER "i - Q <br /> PROPERTY LINE`APYRIVATE DOMESTIC WELL`06 `'PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ;. CONSTRUCTION SPECIFICATIONS <br /> Industrial CablgyTol Dia. of Well Excavation i <br /> Domestic/private �� Drilied i Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> P Irrigation GraveP Pack . Depth of Grout: Seal I ; O <br /> Cathodic Protection Rotary Type of Grout' •- <br /> ' Disposal Other _ Other Information - I <br /> a Geophysical It Surface Seal Ir:'stal-1e4::$y: i_A 3 <br /> PUMP INSTALLATION: Contractor <br /> e <br /> Type of Pump t H.P. <br />( PUMP REPLACEMENT: State Work Done , ; <br /> PUMP .REPAIR. State Work Done + _ � � �,� :t J <br /> ES; IUCTION OF WELL: Well Diameter '4 .; App <br /> y- <br /> ox <br /> ima�te .Depth <br /> Describe Material and Procedure ; tip ; <br /> i <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 j <br /> WELL DRILLERS REPORT of the well and notifythem before <br /> putting. the..wel1 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 FI AL SPECTION. <br /> SIGNED TITLE <br /> { W LOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE '� <br /> ADDITIONAL COMMENTS: <br /> 7,10 <br /> PHASE II W7UTINSPECTIOM PHASE II FI AL INSPECTION <br /> INSPECTION B _ ATE INSPECTION BY DATE <br /> E H 1426 <br /> �c� -k,{ call 7�n �w.4L Lc,SjJrc�i<y <br /> Rev. 1-74 ` <br /> 1-74 2M <br />