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SAN JOAQUIN LOCAL. HEALTH DISTRICT ' <br /> FOF.OFFICE USE: ' 1601 E. Hazelton Ave. , _Stockton, Calif. " <br /> Telephone: (209) 466-6781 <br /> Dkyt 2 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �xw zzdl <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2:::/: �- <br /> r <br /> ' (Complete In Triplicate) <br /> Application is hereby made do the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made incompliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distrw.. <br /> JOB ADDRESS/LOCATION QQ 15 S , fir- Q hiCENSUS TRACTon <br /> l <br /> Owner's Name Pa-u_ C(..l.r4i n , k an S ill-cl e. • Phone <br /> Address City ' <br /> Contractor's Name 5RrDc,. D61i 4, License ## _9&/3 Phone J4S-I1�5 Q' <br /> TYPE-'OF f4ORK (Check): NEWWELL / DEEPEN '/ / RECONDITION / / DESTRUCTION d/_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> . Other <br /> S ..w <br /> DISTANCE: TO NEAREST: SEPTIC-TANK ,�5 ' SEWER LINES PIT PIT PRIVY <br /> r SEWAGE DISPOSAL FIELD CESSPOO zEPAGE.PIT # OTHER ' <br /> PROPERTY LINE - PRIVATE DOMESTIC WA � PUBLIC DOMESTIC WELL <br /> ;INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 'Industrial Cable Tool Dia. of Well Excavation III" <br /> Domestic/private Drilled Dia. of Well Cas-fng CL5 <br /> 'Domestic/public " Driven Gauge of Casing <br /> Irrigation Gravel Pick'- Depth of Grout Seal O' <br /> -Cathodic Protection X Rotary Type of Grout 7 $�• <br /> (Disposal Other Other Information, ! <br /> " 7deophysical Surface Seal Installed By: <br /> E PUMP 'INSTALLATION: Conti actor 4P. <br /> -t Type= of Pump ".ci,!•� H.P. r <br /> PUMP REPLACEMENT: / / :.S-tate-Work Done <br /> PUMP :REPAIR: .— """T�. State Work"Done - <br /> DE-S-T rTl-ON OF WELL: Wel-'1-Diameter .-- Approximate <br /> Depth <br /> 4ee Tdyv e14• olu Desciibe Material and rocedure k <br /> I hereb'�,ag#,ee�toomply ith all laws and regulations of the an Joaquin' Local Health Distr ct <br /> and theiState 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 T :GROUTING AND A FINAL INSPECTION. <br /> SIGNED : TITLE <br /> =i f (ADB&W PLOT PLAN ON REVERSE SIDE) <br /> '-� OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE j <br /> ADDITIONAL COMMENTS: <br /> P -I' GRQUT-INSPECT ON PHASET /FINAL-INSPECT ON <br /> INSPECTION BYMIA,A.,A- DATE INSPkTION BY/ DATI"^�e' <br /> I _1 <br /> s <br /> 177 214 <br /> E H 1426 Rev. 1-74) 1 {'°` <br />