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_ ;,UN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE 0T77TCE U E. 16C Hazelton Ave. , Stockton, Ca;_ <br /> fS '" Telephone : ' (209) 466-6781 '1 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT, Permit No��3 <br /> 'T4 ' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued( �6 <br /> (Complete In Triplicate) <br /> Application is hereby made to th'e 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 Joaquii <br /> County Ordinance No. 1862 and the Rules and- Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION %5/1 P S74p4td CENSUS TRACT <br /> Owner's NameILE Ph ne c?.3 P- ,290 6 <br /> �e <br /> Address Sp1, ze City 4/�rslo/ <br /> Contractor's Name 4// /��a,, 2 / �,,,,' �cs, License #.7.7$/L Phone gt;l-y»t' <br /> M 9-A S 0 IG <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE, TO NEAREST: SEPTIC TANK Lg"-" SEWER LINES1 �y 5-�- PIT PRIVY �- <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT _�� OTHER <br /> PROPERTY LINE --PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> c INTENDED USE TYPE OF WELL. s; CONSTRUCTION SPECIFICATIONS „ <br /> Industrial Cable tTool Dia. of Well. Excavation j Z: <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _.Ir'rigation Gravel Pack Depth of Grout Seal o JC r . <br /> Cahodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B V Wf-e�v <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' --2— <br /> PUMP <br /> "'2 -PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ill I hereby agree to comply with all laws and regulations 6f 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 owledge_and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INS E N. <br /> SIGNED TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) 61FOR DEPARTMENT USE ONLY <br /> PHASE I _ ,- � <br /> APPLICATION AC <br /> CEY��-S.- DATE <br /> ADDITIONAL CO TS: <br /> PHASE : <br /> OUT--INSPECTION P ,- <br /> y*w4mQ <br /> SE : ANAL w <br /> INSPECTION BY —UTE-2 <br /> y <br /> �,�7 7 2M 1 <br /> R. R 1499 moo., . ,_��, <br />