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___ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I'OH OFFICE USE: — 1601 E. Hazelton Ave . , Stockton, Calif. <br /> Telephone : (209) 466--6781. <br /> `r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z14 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issi-d ��.�� of <br /> (Complete In Triplicate) <br /> ApplicationApplication 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 thee San Joaquin Local. Health District. <br /> JOB ADDRESS/ --- .L© CENSUS TRACT <br /> Owner's Name f) ft'•= t Phone <br /> Address _ City <br /> Contractor's Name /'lig /�6. 'f`� ease b� L710 Phone 4 �1 <br /> TYPE OF WORK (Check) : NEW WELL LVDEEPEN ,/_/ RECONDITION DESTRUCTION /-7 _ <br /> PUMP INS ALLATION PUMP REPAIR ! ; PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SLPTTC TANK <br /> ' r. � SEWER T,rINIsS ,�;° <br /> �� 1,, PIT PRIVY <br /> SEWAGE DISPOSAL <br /> ,,IELD "` CESSPOC SEEPAGf? OTHER <br /> _ PROPERTY LINK PRIVATE DOMESTIC WFLL -/-PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL_ ^� CONSTRUCTION SPECIFICATIONS <br /> Industrial-- Cable Tool_ Dia. of- iti'el:. Excavation <br /> x Domestic/private Drilled Iiia. of Well Casi.xtg <br /> Domestic/public �. - - - 4 <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> -DisposalOther Other Information <br /> Geophysical. Surface Seal .Installed B <br /> PUMP INSTALLATION: Contractor4. r r ' <br /> Type of Pump H.P, W ._ �- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure^ - ���� ` -"� <br /> I hereby agree to comply with a,l-1 laws and. regulations of the San. Joaquin Local Health Distrzct <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 knowledge and belief. I WILL CALL F R A GROUT INSPECTIONPRIOR TO GROUTING AND A FINAL INSPECT - <br /> SIGNED TITLE IjL/ 40, <br /> AWP T ON REVERSE SIDE)_ <br /> P I3A 5 E I <br /> FOR DE ARTMENT USE-ONLY <br /> -- ------ <br /> A <br /> APPLICATION ACCEPTED BY DATE , - ` <br /> ADDITIONAL COMMENTS: _ -- <br /> PHAS TI G INSPECTION — P E III INAL INSPECTION <br /> INSPECTION BY DATE - `-� <br /> INSPECTION RY DATE �1 <br /> E H 1426 Rev. - i-74 - 2M <br />