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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.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 <br /> It (Complete In Triplicate) <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.:._.r1862 and the Rules and. Regulations of the San Joaquin Local Health. District. <br /> JOB ADDRESS/LOCATION 01PA) 13 E-u-) 4s T1 CENSUS TRACT <br /> Owner's Name 12A -daC,iE <br /> � Phone ���M' <br /> Address oil rJ�Ll 7• ^ S, k/10 - <br /> Contractor's Name &IL D &UC—i-0P"6A)1'­ SOAP License #a�.33AL Phone <br /> TYPE OF WORK (Check) : NEW WELL /77 DEEPEN / / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTAL TION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /% -�- <br /> DISTANCE TO NEAREST: SEPTIC TANK _ naEr 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 <br /> Industrial- 22.7Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing � <br /> Irrigation <br /> Domestic/public Driven Gauge of Casing 4-D -/0 6-U � <br /> Irrigation Gravel Pack. Depth of GroutI - <br /> 7. <br /> Cathodic Protection Rotary Type of Grout GC &0.s )per iv <br /> Disposal Other Other Informat <br /> Geophysical Surface Seal' Installed By: 0U_),oG <br /> PUMP INSTALLATION: Contractor Lo qT& b+c ` Cnr2P, <br /> Type of Pump C!L Rry-uCri41_ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> FUMP '.REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR U NAL LNSPErTION. <br /> SIGNED <br /> TITLE Q to fy&2 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 0/79r. <br /> ADDITIONAL COMMENTS: <br /> PHAS II, �OUTINSPECTION PHASE I I FINAL INSPECTION 3 <br /> INSPECTION BY ATE IN CTION BY DATE <br /> E H 1426 Rev. 1-74i o: 2M <br />