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SAN JOA UIN LOCAL HEALTH DISTRICT <br /> CT <br /> F,Zd FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;7,37-- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made t6 the San Joaquin Local Health District for a permit to construct <br /> rind/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 fit' Se ---°~ CENSUS TRACT <br /> i <br /> Owner's Nameg 1 bit r a - ...,,.,.,_...._ _.._. Phone i <br /> Address S i A City , <br /> s <br /> Contractor's Name �c4 ,,ice D'° License �7� Phone <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN '/-7 RECONDITION /_" DESTRUCTIONfj f <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 O <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 DrilledDia. of Well Casing <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT.- / / State Work Done i <br /> PUMP :REPAIR: State Work Donee <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I` Describe Material and Procedure <br /> t . <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 well and notify them before putting. the..well. in.use.... The above <br /> F information is true to the best .of- my. o le a elief. I WILL CALL FOR A'GROUT INSPECTION <br /> PRIOR ING AN A FINAL INS . <br />'t SIGNE ITLE <br /> ( W PLOT LAN ON RE RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I . <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P 1/0,1NAWINSPECTION <br /> INSPECTION BY DATE INSPECTION B ,� DATEwez_ <br /> CCS <br /> E H 1426 _Ray. 1-76 T,- - 1t/9t� 9M <br />