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16 JOAQUIN LOCAL HEALTH DISTRICT•, - <br /> I FoTiOFFI�CE USE: 0.. I Hazelton Ave. , Stockton, Cal-_;.1 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZL 3.s3 4) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued y-�-?r1V <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 Joaqui: <br /> County Ordinance No. 1862 and the Rules and /Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � � �d• / "/�/V f} / CENSUS TRACT <br /> Owner's <br /> Name,., <br /> Phone <br /> ✓ <br /> Address 565' =5;:n6 A'/q-v 9 w e--- Cit . <br /> Cont ' y 3 <br /> ctor s�Name License 0 Phone <br /> OLLIE <br /> TYPE OF WORK (Check): NEW WELL 'fo DEEPEN /7 RECONDITION /`7 DESTRUCTION /7 <br /> PUMP INSTALLATION /V PUMP REPAIR /_7 PUMP REPLACEMENT / U <br /> Other _/_7 <br /> ! CR <br /> DISTANCE TO NEAREST: SEPTIC TANK / SEWS�,JLII,NE PIT PRIVY "y <br /> SEWAGE DISPOSAL FIELD W` ;i-CESSPOOL/SEEPAGE PIT OTHER <br />' PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> k INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAZIMS . <br /> IndustrialCable Tool Dia. of Well Excavation <br /> Domestic/private ' Drilled i Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /40 <br />' Irrigation Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection X Rotary Type of Grout Q J <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> s <br /> FUMP''INSTALLATION: Contractor ZIA=-47-191-. P4.J A-! f <br /> Type of Pump "7"1J H.P. <br /> PUMP 'REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /'7 State Work Done <br /> ES.TRUCTION OF WELL: Well Diameter Approximate Depth <br /> t .. <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED , )4 _ _ TITLE <br />' DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR ARTMENT USE ONLY <br /> _. <br /> APPLICATION �T- <br /> ACCEPTED BY V . AI. DATE <br /> ADDITIONAL COMMENTS: w <br /> PHASE II GROUV INSPECTION PHASE III F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z' <br /> ,� E H 3.426 Rev. 1-74 <br /> 1 .74 9M <br />