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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE &FIC-E USE: � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> s AZO Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ]7- � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued P11--7 <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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquiri,,Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name 4r,- . . . Phone '1D 2 -Q 2 91S <br /> Address city .SesOlow <br /> Contractor's Name License Phone /S2 <br /> " "�' +M-�--` �w"_moo-:-rs�.. �-..,-- ".._.._.. i-i--.� i ..i-.-ii-.--.�� - _- _- —__ -...i..��••.•� may.'d <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES 400'-j-PIT PRIVY �-- <br /> SEWAGE DISPOS FIELD G SL/SEEPAGE PIT _ OTHER --- �� <br /> PROPERTY LINE SPOO <br /> PRIVATE DOMESTIC WELL "p PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL + CONSTRUCTION SPECIFICATIONS �, <br /> Industrial Cable Tool .Dia. of Well Excavation <br /> _ Domestic/private Drilled. Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing J2 + + <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout easjLadzN 4 <br /> Disposal Other Other Information <br /> Geophysical Surf ace Seal Installed By: ,r-S - <br /> PUMP INSTALLATION: Contractor o� S <br /> _ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: _, State Work Done <br /> PUMPTREPAiR: r" �_ / / State'Wozk Dona ' <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 '-const-ruction. Within FIFTEEN DAYS <br /> aftercompletion 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 th be t of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T NG &D A F NS ION. <br /> SIGNED TITLE <br /> (DRAW-.PLOT _PLAN. ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I F <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I GRO INSPECTION PHAU IIVFINAL INSPECTI N <br /> INSPECTION BYDATE ��� INSPECTION BY DATE <br />