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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <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 8.-(-76 <br /> tt <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 of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Q9 1 ,35 -- Lo,6- Tr�e,,_- PW, 0 ENSUS TRACT <br /> Owner's Name . Lu� Phone 838_ 7-IDO <br /> Address S>,,^ City <br /> Contractor's Name d:�'z, , License= 79oIy Phone�S, n2-2d7 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN '/—/ RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION /1-rPUMP 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-7- Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing (30 <br /> Domestic/public 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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 'O <br /> Type of Pump H.P. 4- <br /> PUMP REPLACEMENT [ State Work Done T S <br /> PUMP .REPAIR: State Work Done <br /> AES,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Sar, 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 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 <br /> information is true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AMR,4 FI AL INSPECTION. <br /> SIGNED TITLE <br /> D W. PL T PLAN ON R V_E_RSE SI E f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY f DATE <br /> ADDITIONAL COMMENTS: j — -- <br /> PHASE II GROUT INSPECTION P S I / N INSPECTION <br /> INSPECTION BY DATE INSPECTION $ DATE <br /> r _ <br /> E H 1426 Rev. 1-74 ' 376 2M <br />