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^� SAN JOAQUIN LOCAL.. HEALTH DISTRICT C _ <br /> FOR-OFFICE USE: ' 1601 E. Hazelton Ave. , Stockton, Calif. I�I <br /> Telephone: (209) 466--6781 /Jq f <br /> APPLICATION FOR 'WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1-7 ,5t) 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Applicationishereby 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 Na. ,1862. and the Rules and Regulations of the San Joaquin Local Health Dist#ct. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> i <br /> Owner's Name / 1 <br /> C �"�ione a ,s <br /> Address - / L .a- City ,_ ` <br /> Contractor's Name �Anj4_ L�� �!~1 - License # a3 Phone <br /> TYPE OF WORKCheck) : * <br /> { NEW WELL,' DEEPEN /�% RECONDITION /_7 DESTRUCTION /_7 .. <br /> PUMP INSTALLATION' / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other — <br /> UISe- <br /> TANCE TO NEAREST: SEPTIC TANK SEWER LINES/-ODO Lj' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE-Z5�PRIVATE DOMESTIC WELT/O= f- PUBLIC DOMkSTIC WELL—A— <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ` <br /> .Industrial 2KCable Tool Dia, of 'Wel1 Excavation Q . <br /> Domestic/private Drilled Dia, of Well Casing i <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: 42i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. . : . . <br /> PULP REPLACEMENT: <br />_ / / State Work Done � <br /> rPOIP •.REPAIRi-� <br /> DESJ tUCTION OF WELL: -'Well'-Diameter Approximate'Depth <br /> - Aescrib'e Material, and Procedure <br /> I 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 of the waandZOwg <br /> fore utting the .well in use. The above <br /> informatio s t ue to a bebelief. I WILL. CALL FOR A: GROUT INSPECTION <br /> PRIOR T G AN FINAL <br /> SIGNED. TITLE. <br /> P OT; PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY ! <br /> PHASE T <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN ECTI ._- PSjkjlT/F AL INSPECTWN <br /> INSPECTION BY DATE i IINSPECTION BY DATE d . <br /> E -H-1426 Rpv. 1_7-43 - ~ . . rt . ., _ 7: _ 2M <br />