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16 SAN JOAQUIN' LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E.. Hazelton Ave. , Stockton,' Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 ?16 r? GOGcJ 6- t. S CENSUS TRACT <br /> Owner's NameU Lx Phone <br /> Address F,7o W cr.v c City _�•? �.�" -�- <br /> Contractor's Name d ry ,� License # i- hone <br /> _ <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ � RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR %/ PUMP REPLACEMENT /"7 <br /> Other j_7 <br /> a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY T . <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 . 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: f <br /> PUMP INSTALLATION: Contractor a � l <br /> _ 5 <br /> Type of Pump s-1` 61 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done v <br /> DES-TRUCTION OF WELL: Well Diameter " Approximate Depth <br /> Describe 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 well and notify them before putting the -well in use. The above <br /> information is true to .the best of my owled and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G U ING AN9 A FINAL INSP ON. <br /> SIGNEDITLE <br /> !'!(j"4L6rf PLAN ON RLnKiZSE SIDE)^ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYD TE _.3-7 _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION, P NAL INSPECTION _/} <br /> INSPECTION BY DATE INSPECTION DATE U ". � ' r <br /> E H 1426 Reu. 1-74 3176 2M <br />