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JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF •OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> 7EP :hone <br /> Tele <br /> P (209.) 466-6781 <br /> APPLICATION FOR WELL CPNSTR+JCTION OR PUMP PERMIT Permit No. 7i Z <br /> THS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued 5 <br /> 661 <br /> In <br /> Application is hereby made to the San(JoaquineLocalrHealthtDi'strict 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 Joaquin Local Health District. <br /> r JOB ADDRESS/LOCATION � � �� �1 • <br /> �� C - CENSUS TRACT <br /> Owner's Name c5X 8 S GI�Q <br /> Phone r� 3 , <br /> Address 19 <br /> City � T <br /> Contractor.'s Name � Y /1 <br /> License # Phone <br /> I TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_% DESTRUCTION /7 <br /> E PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 ..E <br /> .. : <br /> Other.!/ 7- — <br /> k _ Y <br /> DISTANCE TO NEAREST: SEPTIG.TANK /Op SEWER LINES PIT PRIVY <br /> SEWAGE'DISPOSAL FIELD � CESSPOOL/SEEPAGE PIT OTHER e0f,(-S p��] <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELT.INTENDED �- <br /> USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V-1 <br /> fl <br /> Industrial Cable Tool Dia. of Well Excavation /��� � <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public ! Driven Gauge of Casing <br /> Irrigation 1 Gravel Pack Depth of Grout Seal �• <br />? Cathodic Protection t Rotary Type of Grout ,J <br /> Disposal i Other Other Information tom/ <br /> Geophysical Surface Seal. Installed B ;� � <br /> PUMP INSTALLATION: Contractor <br /> Type of 'Pump H.P, . <br /> PUMP- AEPLACEMENT: <br /> / / State Work .Dane <br /> PUMP .REPAIR: / ./ State Work Done <br /> DESTRUCTION OF"MELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure j <br /> i <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 wLll 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 FORA GROUT INSPECTION f <br /> PRIOR TO GR UTING FINAL I INSPECT ION <br /> SIGNED ; <br /> TITLE <br /> 1 (DRAW PLO LAN ON REVERSE SIDE) ! <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL- COMMENTS: <br /> P __ I GROUT INSPECTION\ PHASE /FIN4L INSPECT ON <br /> INSPECTION BY DATE �. �\7�' INSPECTION BY IAII DATE t <br /> r w /E H 1426 Rev. ,-I--74 <br />