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11,71119 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,� 4cj <br /> THIS PERMIT EXPIRES 1 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/ox 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/LOCATIONzmx alwgzi XIl Al, ' NSUS TRACT <br /> Owner's Name L Phane w 3y qy, <br /> Address 93$ City <br /> 47 <br /> Contractor's Name License # ..�Phone <br /> TYPE OF WORK (Check): NEW WELL/�i DEEPER RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR-1-7 PUMP REPLACEMENT /7 <br /> Other /-7 — <br /> DISTANCE TO NEAREST: SEPTIC TANK /W SEWER LINES f PIT PRIVY <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PIT MR <br /> PROPERTY LINES PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /" <br /> V_ Domestic/private Drilled Dia. of Well Casing 5 <br /> Domestic/public Driven Gauge of Casing1412 ,q <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ✓ Rotary Type of Grout <br /> Disposal Other �� Other Information 131,4 <br /> Geophysical Surface Seal Installed BY:.,vOr <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / IT State Work Done <br /> PUMP :REP_AIR: /7 State Work Done <br /> E&TRUCTION OF WELL: Well Diameter Approximate Depth j <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-beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO QROUTING ANDA F AL INSPE 12 1. <br /> SIGNED DRAW P PLAN ON", TLE <br /> SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: -- 4 <br /> PHASE II GROUT INSPECTION PHAS I I FINAL INSPECTION <br /> INSPECTION BY;� DATE �- 4 �� INSPECTION BY DATE <br /> 1EH1 <br /> 426 Rev. 1-74— — - 1-74 2M4. <br />