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Com SAN JOAQUIN LOCAL HEALTH DIS <br /> FOR:O ICE USE: DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 4 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6Jos <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued J l yZS- <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 �"�: <br /> CENSUS TRACT 1`E5 - 23t7-a`( <br /> Owner's Name •�" �' �� . 0 <br /> Phone . <br /> Address D WJ ra City , <br /> Contractor's Name <br /> License # C 'phone <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN '/-7 RECONDITION DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR ff. PUMP REPLACEMENT <br /> Other _.�.. <br /> DISTANCE TO NEARESTo SEPTIC TANK SEWER LINES RIT 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` Drilled Dia. of Well Casing a <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout. Seal <br /> Cathodic Pr-otection Rotary Type of Grout i <br /> Other O <br />-Disposal i <br /> P ... . Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor � � # <br /> Type of Pump. =Mje_h foe H.P. <br /> UMP REPLACEMENT: / / State Work Done` <br /> PUMP_REPAIR: A State Work Dones � e � <br /> ,. &J a rigy <br />)E&TRUCTION OF WELL: Well Diameter ' Approximate Depth <br /> Describe Material and Procedure <br /> T 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 /> ifterticompletion ofmy work on a new well, I will furnish the San Joaquin Local Health District # <br /> 4ELL DRILLERS,RREPORT of the well and notify 'them before putting. the."well. in.use... The above <br /> Enf1rimatioW is true to the-best.of-fm <br /> AIOR TING A VINAZ <br /> y owled a and b ief. I WILL CALL FOR A GROUT INSPECTION j <br /> 0 <br /> SIGNED TLE <br /> (D L T PL ON RE SE SIDS -. <br />'RASE I R DEPARTMENT USE ONLY <br /> L'PLICATION ACCEPTED BY _74_LzD <br /> 1DDITIONAL COMMENTS: <br /> PHASE II. GROUT INSPECTION PHASE. NSPECTION } <br /> INSPECTION BY DATE INSPECTION ,BYADATE <br /> r - <br /> E .H1426 - __. ��_ . � �`�` .�'✓ , <br /> - _ Rev. 1-74 r " h/75 2M <br />