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`., SAN JOAQUIN LOCAL HEALTH DISTRICT ~ j <br /> f, <br /> 2'06.,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif <br /> Telephone: (209) 466-6781 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �6�4:) <br /> ;;-6-,3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct <br /> and/or instar, 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/LOCATIONL!. T 7 <br /> ---�-- �, D � CENSUS TRACT <br /> Owner's Name 40L Phone. '_�' Z <br /> Address /S6 SFS Gc, Z 74 city., &f 1z.c_1 <br /> Contractor's Name <br /> .�l�L�" � _,. c-d .. ..- _License � Phone g <br /> TYPE OF WORK (Check): NEW WELLff DEEPEN '/ RECONDITION/-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR/� 'PUMP REPLACEMENT f <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 Cable Tool Dia. 'o£'Well EkdAvation <br /> K_ Domestic/private Drilled ., Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing is <br /> Irrigation Gravel Pack Depth of Grout Seal, <br />• ,� Cathodic Protection Rata - <br /> ry Type of Grout <br /> Disposal. , Other . Other Information. , <br /> Geophysical ' �; . Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor = ► <br /> Type of Pump s' f <br /> H.P. 1 <br />.PUMP REPLACEMENT: � <br /> State Work Dane <br /> AQP 'I ;FAIR: 1-T"State Work�lone <br /> .. <br /> DESTRUCTION -OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br />�1 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 /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT -o£ the -well .and- notify. them before putting:-the-well in'.'u's'e.... The above <br />`information is true to the•best.of- my..Icne wl''edge~arid._belief-. :I WILL -CALL:XOR 'A-GROUT INSPECTION <br /> PRIOR TO GROUTING D A' FINAL INSPECTION. <br /> SIGNED­ <br /> f. TITLE <br /> W <br /> FLOT, PLAN ON REV.ER_ SE <br /> FOR DEPARTMENT USE ONLY - _ `i�• <br /> PHASE I ] <br /> APP-LICATION ACCEPTED BY DATE <br /> ADDITIONAL COHNENT S: <br /> PP,j&VAI GROUT INSPECTION f PHASE ;jjfFINAL;FINALINSPECTION <br /> INSPECTION BY DATE - INSPECTION BY. DATE <br /> E H 1426 Rev. 1-74 _ f <br /> t./y C stir f <br />