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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> LFOFk,__:5FF1fCE USE. 1601 E. Hazelton Ave% , Stockton, Calif. <br /> r <br /> Telephone:P (209) 466-6781 .� <br /> APPLICATION FOR WELL CONSTRUCTIONTOR-PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued F 13-7s <br /> (Complete In Triplicate) , yq-�A�) <br /> Application is }iereby made to the San Joaquin Local Health District for a permit to construct <br /> t and/or install the work herein described. This application is made in compliance with San Joaquin <br /> Count Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> f��So �� 11r6►�Ew,� �f f - <br /> i JOB ADDRESS/LOCATION si 14 SiF �,�► CENSUS TRACT ^ <br /> Owner's Name e cr_ f tr -+-c� Y- - Phone <br /> • Address G 4 city - � Y <br /> Contractor's Name License # /E�2.,wT­phone -],r <br /> TYPE OF WORK (Check): NEW-WELL /_7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION f f <br /> PUMP INSTALLATICN /7 PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private o <br /> Drilld a. E <br /> of Well Casing € <br /> Domestic/public Driven Gauge of Casing SRI <br /> Irrigation Gravel Peck Depth of Grout Seal '"��✓-I <br /> Cathodic Protection Rotary Type of Grout l <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installdd"B :- - j <br /> PUMP INSTALLATION: Contractor ,! <br /> Type of Pump w H.P. <br /> PUMP REPLACEMENT: State Work Done � 1r <br /> PUMP '.REPAIR: />C/ State Work Done r.)/_dws, CLA,442/ Z-1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 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 be my know ed- ;and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING DAF SPE T <br /> SIGNED <br /> -4°/oaf <br /> DRAW PLOT PLAN 0 A.ERS E) <br /> PHASE I FOR DEPARTMENT -USE ONM <br /> APPLICATION ACCEPTED BY DATE -jj <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION �;; PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE 'I IONBY DATE S <br /> AA a� <br /> H,142b Rev. 1-74 ; h/75 2M <br />