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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OF ICE USE: v� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 4- <br /> Telephone: (209) 466-6781 <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 /> 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations <br /> /of/ the <br /> San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .9n. // O�� JIA}R��LNdaGGc svmgr�i� YM6UiNSUS TRACT ' �S <br /> Owner's Name Q.OpAD Phone <br /> Address `d� st_ City <br /> Contractor's Names S7"d V/'�,�` .t�.s License #/ -72-j"phone (� <br /> TYPE OF WORK (Check): NEW WELL DEEPENS/ % RECONDITION /7 DESTRUCTION /7 i <br /> PUMP INSTALLATION '/ / PUMP REPAIR _7PUMP REPLACEMENT /7 <br /> Others/ / <br /> F <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES "PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> DOMESTIC PROPERTY LINE - PRIVATE DTIC WELL — PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> C. Industrial ,.l Cable Tool Dia. of Well Excavation. <br /> Domestic/private I Drilled Dia, of Well Casing _ <br /> Domestic/public 3 Driven Gauge of Casing <br /> Irrigation L Gravel Pack Depth of Grout Seal p <br /> Cathodic Protection I Rotary Type of Grout �f <br /> Disposal ! Other Other Information <br /> Geophysical1Fi Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type,of Pump <br /> , <br /> _ 1 <br /> PUMP REPLACEMENT: . J / 'State Work Done !� <br /> 1 <br /> PUMP:.REPAIR: /X/ State Work Done l�p,yr b "lde A AV AUw4v <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> a 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 anew 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 know1 dg d belief. I WILL CALL FOR A GROUT INSPECTI N <br /> PRIOR TOG UTING AND A FINAL} INSP CT N <br /> SIGNE TITLE `{'✓a-/ - <br /> 1 C2RAW:P1VT PLAN ON F4RVERSE SIDE) <br /> FO D ARTMENT,USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT Y % �/GO DATE <br /> �TIONAL COMMENTS: ''I <br /> PHASE II !LRM .INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATE 96 <br /> t. <br /> 'E H 1426 .Rev. '1-74 <br /> 3/76 2M <br />