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� 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT. ❑ � <br /> 47 <br /> FOR OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. �� y <br /> Telephone: (209) 466-6781e <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> r s Application is hereby made to the Son Joaquin Local Health District for a permit to construct 4 <br /> and/or install the work herein described. This application is made in compliance with San Joaquin. <br /> County Ordinance No. 1852 and the Rule and Regulations of the San Joaquin Local Health District;. <br /> .TOB ADDRESS/LOCA /✓ J 'e <br /> � CENSJU5 TitACT� <br /> /�" ��•_."; <br /> § Owner's Na-el <br /> Y" <k~� Addressy`. >� L�• city,%: <br /> Contractor's Name ,B License �a373PhoneAcgz qgjq <br /> 0. TYPE OF WORK (Check): NEW WELL ELL DEEPEN /-7 RECONDITION /_7DESTRUCTION - <br /> PUMP INSTALLATION /% PUMP REPAIR/? 'UMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE ZISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �': fY• <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL:____ PUBLIC DOMESTIC WELL—­­­ <br /> INTSNDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS w , "Q <br /> ` Industrial Cable Tool Dia, of Well Excavationa '� w ' <br /> ;;' Domestic/private Drilled Dia, of Well Casing, <br /> _ ,:i� <br /> u . <br /> ,�F<= Domestic/public Driven Gauge of Casing : <br /> Irrigation Gravel Pack Depth of Grout Seadq <br /> l <br /> M Cathodic Protection Rotary Type of Grout <br /> s :. Disposal Other, Other Information , <br /> a=j Geophysical Surface Seal Installed By:�,_ . <br /> i * PUMP INSTALLATION: Contractor <br /> _ SY 5- <br /> �a pe of Pump H.P. _ A <br /> r1 PUMP REPLACEMENT: / / State Work Done ' <br /> a4 PUMP :REPAIR:. F-7 State Work Done ' <br /> ; DESTRUCTION OF WELL: Well. Diameter j/d f? Appr ximateh <br /> D cribs Mlatertal and Procedure ,.yv C-1- �+ # <br /> 9t- <br /> zr- <br /> N I hereby agree to comply with all laws and regulations of the San Jbaquir. Local Health District': £ '. <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> r� .n 4 w • ��' <br /> =M M 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 , 1 <br /> n information is true to the-best•of' my knowledge and belief. I WILL Ct.LL FOR A GROUT INSPE ION .• <br /> - ." PRIOR TO GROUTING .LND A FINAL INSPECTION. <br /> . r <br /> yL SIGNED T',t d Jr� r �:' TITLE )J <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I e <br /> APPLICATION ACCEPTED BY DATE <br /> ENT <br /> ADDITIONAL COMMS: L- <br /> rt.' PHASE II GROUT INSPECTION PHASE III FINAL INSP$CTI N <br /> INSPECTION BY DATE INSPECTION BY ��/ <br /> DATE ,_i ,_n J <br /> '' E H 1426 Rev. 1-74 h/75 2M <br />