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fj G� PFO <br /> Ce9s� ���es�C SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I .,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z!Lo d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued r-5_-,2Z <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 A A�t,ne , CENSUS TRACT <br /> Owner's Name IS' M�t.rQ i Phone 1 3/- <br /> Address 13`o Al A IL n City <br /> Contractor's Name S 0 e// or License # /S3 7ArPhone V4CX-7974 <br /> TYPE OF WORK (Check): NEW WELL / N DEEPEN /? RECONDITION /7 DESTRUCTION �T <br /> PUMP INSTALLATIO /7—pump REPAIR'/-7 PUMP REPLACEMENT �X�I <br /> Other/7 <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. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing p <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 ._ �p <br /> Type of Pump Tk r A H.P. /.r'_ <br /> PUMP REPLACEMENT: , / State Work Done ? % I-JP to 1r.- *Q <br /> PUMP ;REPAIR: /_7 State Work Done <br /> DEST'R,UCTION 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 o£ my.knowled a and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTIO . <br /> SIGNED �kl TLE <br /> D W 4ELOT PLAN ON R SE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHAS I F AL INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 77 <br /> E H 1426 Rev. 1-74 2M <br />