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SAN JOAQUIN LOCAL HEALTH DISTRICT' <br /> FORrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZE;S?l/lr�; <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) i <br /> Application is hereby made to the Sara 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 Joaquin Lo al health District. <br /> JOB ADDRESS/LOCATIONr / TRAAw <br /> orm CT <br /> 4"�� <br /> Owner's Name on <br /> Address City v <br /> Contractor's Name . License VS + 6 hone <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /7 RECONDITION / DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION REPAIR 1-7—Pump REPLACEMENT ff <br /> Other / / ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER -LINES PIT PRIVY f_ <br /> SEWAGE DISPOSAL FIELD � CESSPOOL/SEEPAGE PIT i OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC*`.DOMESTIC WELL:- ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS "(h} <br /> Ind trial Cable'Tool Dia:' of Well Excavation".- \ <br /> ostic/private Drilled • ' ` y Dia:- of Well Casing <br /> ,...Domestic/public Driven Gauge of Casing E 8 <br /> 1 Irrigation _ -`_�"' �7_Gr`avel" Pack-----DeQth--flf-rGr-out- l_.:. "-_ <br /> i Cathodic Protection Z'--iro-tary Typey - - <br /> of-Group <br /> Disposal Other Other Information <br /> ' Geophysical Surface Seal Installed BX:?I <br /> PUMP INSTALLATION: Contractor '"-- <br /> Type of Pump H.P. / f <br /> PUMP REPLACEMENT: / / State Work Done r� , <br /> F % <br /> PUMP :REPAIR: /�(State Work:%,Done _ } <br /> ESTRUCTION OF WELL: Well Diameter dam. - Approximate Depth <br /> DescribeaMaterisl-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-S'an Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe well in-use.. The�'above'- <br /> info ation is true to the best of my knowledge and belief. I WILT, GALL FOR A GROUT'INSPECTION <br /> PRIOR GROUTI i PECTION: <br /> 5I TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATE 2 <br /> ADDITIONAL COMMENTS:"BY i <br /> FHA II GRO T INSPECTION , PH= XWEINAL INSPECTION <br /> INSPECTION BY DATEINSPECTIONBY DATE <br />�t ~E H 1426 Re'v'.-1L74 4 , <br /> ►-- 7-7/. 7LR - -.. <br />