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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR• OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. j� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X76 <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 /> �- .CP7 .• ..$, ,., . I,&-_ <br /> �CENSUS TRACT Od7-/�Fo LS <br /> JOB ADDRESS/LOCATION ofelJ � <br /> 45 Phone-� — Q 37 <br /> Owner's Name <br /> 9 3 City <br /> Address ' <br /> License *#'1�2313 _ Phone3 i -> .3'"' <br /> Contractor's Name <br /> 1-7 <br /> TYPE OF WORK (Check) : NEW WELL/ '/ DEEPEN-/ I RECONDITION / / DESTRUCTION — . <br /> PUMP INSTALLATION I I PUMP REPAIR r` PUMP REPLACEMENT /-T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> "PROPE TY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE LZ-Y-P-E OF WELL CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> 'Industrial O <br /> Domestic/private "Trilled Dia. of Well Casing <br /> Domestic,/publi'c Driven Gauge of Casing ' <br /> Irriga"tion''" . ��� _�_ avel Pack Depth of Grout Seal <br /> �C3.r <br /> Ro ary -- .---Type f Givut <br /> Cathodic Protection <br /> Other Information <br /> Disposal Otlier _ ionI � <br /> Geophysical Surface Seal Installed By: <br /> , <br /> ,PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump i e <br /> PUMP REPLACEMENT: . / / State Woo Done <br /> PUMP "REPAIR <br /> State Wollel one r <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate epth <br /> Describe Mate4ia-1 and Procedure <br /> I hereby agree to comply with all .,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 .completi.an of my work on4ad. <br /> ll, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the wetify them before putting the well in use. The above <br /> information is true to the besnowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G TI G AN A INAL N. TITLE <br /> SIGNED I <br /> W PL T PLAN ON RE FRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I l � <br /> � DATEAPPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: E PHASE III/FINAL INSPECTI N IZ <br /> PHASE II GROUT INSPECTI N INSPECTION BY � , DATE D <br /> INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1--74 <br />