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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEfOFFTCE USE: ' <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,1 !/Q <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -7-75' <br /> (Complete In Triplicate) �2-V7--t&o_ob <br />' Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> jand/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 Local Health District. <br /> JOB ADDRESS/LOCATION <br /> S! 4 CENSUS TRACT <br /> w. r � . <br /> Owner's Name � 00 <br /> 1-5 Phone J�,39 - 7o6 6 <br /> f Address <br /> City L C il,4 o,� <br /> Contractor's Name 1v ''�- � Y1 _ <br /> License #�ao Phone S�38 <br /> TYPE OF WORK -(Check):-.--NEW -WELL L7 DEEPEN /7 RECONDITION /7 DESTRUCTION '/7 <br /> PUMP-INSTALLATION / / PUMP REPAIR 1-7—Pump REPLACEMENT <br /> L� . <br /> Other %/J _.. EMENT �f <br /> "o <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , PIT PRIVY <br /> SEWAGE DISPOSAL FIELD .CESSPOOL/SEEPAGE PIT OTHER CN <br /> INTENDED USE <br /> PROPERTY LINE _ PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Indust�r I Cable Tool � Dia. of Well Excavation <br /> Domestic/Domestic/private Drilled . ,,Dia. of Well Casing <br /> Irrigation <br /> _ Driven ,,Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ' � -_ Other Other Information. <br /> Geophysical ---�- �. <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump rt <br /> <.. H.P. <br /> PUMP REPLACEMENT: ) State Work Done_ : - <br /> , / <br /> r.,� - --_ .�f _ <br /> - f_-- .K -. _� —. <br /> PUMP /7 State Work Done : _ .�--- ,=-r .-. .._... .�- <br /> 4 <br /> ES TRUCTION OF WELLa Well Diameter <br /> Approximate Depth . <br /> Describe Material and Prote:dure ------ <br /> y . g <br /> I hereb .a ree to .comply with all laws and regulations of the San 'Joaquin Local Health District <br /> and the 'State of California,pertainAj"to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of,.my work-, on,atnew- well, I will furnish the Safi: 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 knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR. TO GROU NG AND A N INSPECTION. <br /> SIGNED <br /> TITLE T <br /> DRAW PLOT PLAN ON REVERSE SID <br /> PHASE I FOR DEPARTMMM USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY INSPECTION III FINAL INSPECTION <br /> r DATE INSPECTION BY Off° ' DATE <br /> E H 1426 Rev.. 1-7;.l. <br /> 1-74 Im <br />