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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS_.PERMIT, EXPIRES 1 YEAR FROM DATE ISSUED. Date Issued ,r-1 70 <br /> � j2 g S 9.Alp {¢;p,ag_.J= :- , (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to cpnstruct <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 Ai 14-_ Z / '{ &0!i7_0_) CENSUS TRACT <br /> -3� <br /> Owner's ,Name f9f�. �'Ci{�1,�'1I719 Phone <br /> Address E'—151 <br /> City �� d/✓_ <br /> . <br /> Contractor's Name �� _-�— License # Phone� �� <br /> h} <br /> TYPE OF,,WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION ./ / DESTRUCTION /_7 <br /> PUMP INST—ALLATIONiJ PUMP REPAIR / / PUMP REPLACEMENT /� <br /> --- — — <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK JWO SEWER LINESU-0 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPf,GE PIT -- _ OTHER } <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL L PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC IONS <br /> Industrial '- , Cable Tool Dia, of Well ExcavationI <br /> Domestic/private Drilled Dia, of Well Casing ' <br /> Domestic/public Driven Gauge of Casing <br /> >C Irrigation Gravel Pack Depth of Grout Seal <br /> ^T^ Cathodic Protection Rotary Type of Grout � <br /> Disposal Other Other Information <br /> Geophysical Gni �� 5 Surface Seal Installed By: <br /> +. .-83� <br /> PUMP INSTALLATION:' Contractor <br /> 16 Type of Pump <br /> PUMP REPLACEMENT: f / State Work Done <br /> PUMP .REPAIR: ' / State Work Done <br /> DESTRUCTION OF WELL:% Well Diameter Approximate Depth { <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 GROUZING AND A F, AL SPECTION. -�-- <br /> SIGNED .: .- ".� � TITLE 'l <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ��/f� p- <br /> APPLICATION ACCEPTED BY 11 DATE ;Z" 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE /FIN NSPECTION. <br /> INSPECTION BY DATE INSPECTION <br /> b"77 _ 2M <br />