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a SAN JOAQUIN CAL,-HEALTH DISTRICT <br /> i <br /> FOE.OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. ``1� D� <br /> Telephone; (209) 466- -1 <br /> APPLICATION FOR WELL CONST.NCTION OR PUMP PERMIT Permit No. <br /> l F 9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �- <br /> (Complete In Triplicate) A <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 andtthe Rules and Regulations of the San Joaquin Local Health District. ;4 <br /> "� CENSUS <br /> JOB ADDRESS/LOCATIOI3 <br /> TRACT <br /> . - P}ione <br /> Owner's Name P S 7r <br /> City - -f . <br /> Address . <br /> .. r - License It"IM13 Thone SSS= ST. <br /> Contractor's Nage 3- 2 /�/� <br /> �7f4liG'_ <br /> fi . <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/_/ 'RECONDITION / DESTRUCTION <br /> _ _ W <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT . I7 -- , <br /> Other /_7 „. <br /> DISTANCE TO NEAREST: SEPTIC TANK r,f SEWER LINESy PIT P IVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OT#�ER <br /> PROPERTY LINE .- PRIVATE DOMESTIC WELL �* 5� PUBLIC DOMESTIC W LL <br />• INTENDED USE TYPE OF WELL CONSTRUCTION SpECIFICATI NS �• , <br /> Industria Cable Tool Dia. of Well Excavation <br /> Domestic/private x Drilled Dia. of Well Casing <br /> Driven Gauge of Casing <br /> Domestic/public <br /> --. -- Irrigation Gravel Pack Depth of Grout Seal G „ <br /> Cathodic Protection _ t Rotary Type of Grout 21 <br /> ' <br /> Disposal Other � -_ Other Information �W � z <br /> Geophysical i Surface Seal Installed B - <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: /�/ . State Work Done <br /> PUMP '.REPAIRState Work Done <br /> _ : _ <br /> // ;.� ' <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth" _ <br /> Describe Material and Procedure <br /> I hereby agree°to -comply <br /> With all aws and regulations of the San Joaquin Lgga1 Healtih Pistrict <br /> and the State of Californiapertaining to or regulating we11'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 tWwell and notify them before putting the well in use. <br /> The abo*e <br /> aLnformat�on is . true ;to the best of my knowledge and belief. I WILL CALL FOR AA QR�OUT IN$PS ION <br /> I PRIOR TO'GROUTING AND A FI AL INSP- CTIA TITLE <br /> SIGNED " <br /> {DRAW OT PLAN ON QN REVERSE SIDE <br /> OR DEPARTMENT USE -ONLY <br /> PHASE I DATE <br /> APPLICATION. ACCEPTED By <br /> ADDITIONAL COMMENTS: PHASE II/ElfAL .LN5PEC ON <br /> PHAS 11 ,• ROUT. INSPECTION <br /> INSPECTION BY DATE /1-7 INSPECTION BY <br /> ., .• 1 1.hG n..-- T_7 A <br />