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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0K70FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> c <br /> 1 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued � >G <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 /> f County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION ,E- 111A R L S7`K CENSUS TRACT <br /> Owner!s NameC (� 490 9� <br /> f Phone -. <br /> G Address <br /> Z- --AlLr�"]� �� Cit <br /> 1 y <br /> Contractor's Name F— fj4Ct+APD CC « _ License ! hone <br /> 2 4f T77 <br /> TYPE OF WORK (Check): NEW WELL _/ �;DEEPEN './ -RECANDITIO /? DESTRUCTION /-7 r <br /> PUMP INSTAL ?� <br /> ION E/ PUMP RE <br /> Other ;/ <br /> PAIR /? PUMP REPLACEMENT ��,_ <br /> s <br /> a <br /> DISTANCE TO..NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 4 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT t OTHER. ., <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WE'LL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria] w Cable Tool Dia. of Well Excavation �+ <br /> Domestic/private Drilled Dia. of Well,'Casing ., <br /> Domestic/public i Driven Gauge of Casing vA+ <br /> Irrigation _ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type. of GroutiV�Z9nf <br /> Disposal _ + .,. ,, <br /> Outer , Other Information ,e-- _ r <br /> Geophysical " <br /> Surface Seal Installed 'By <br /> PUMP INSTALLATION:, Contractor <br /> ► t - , rz�. � . , <br /> Type, .of Pump # .. % <br /> H.P. <br /> PUMP REPLACEMENT / / State Work Done f <br /> State Work Doris, { <br /> DES_TRUCT:ION OF WELL: Well Diameter J Approximate Depth <br /> DescriVe Material and­P,rocedure-- <br /> s <br /> - <br /> t <br /> I hereby g'ree_to complywith `all ,laws and regulations of the San Joaquin Local Health District <br /> and the .State of Cali fornia"'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 '11-�and notify them before putting..the .well in.use.... .The above <br /> information is t ue to the• a o£. my knowledge and belief. I WILL CALL FORA GROUT INSPECTION 4 <br /> PRIOR TOG G 'AND A VI CTI <br /> SIGNED <br /> TITLE <br /> ( RAW PLOT PLAN ON REVERSE SIDE <br /> DEPART T <br /> PHA � USE ONLY <br />--...� <br /> APPLICATION ACCEPTED—By A <br /> KZ642: , 0� .1 )ORIQ9RADATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION 1 PHASE III FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY DATETA-el� 44P <br /> E H 1426Rev. 1 7 � - *.- r, S?v// 54-r1Co`'7'7 � <br />