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SAN JOAQUIN LOCAL HEALTH DISTRICT Y <br /> FOV OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /a <br /> 44f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �' 7tl <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 incompliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,3q 3!Z Ale 11 fPA721 0y 12 Q1 CENSUS TRACT <br /> ) <br /> Owner's Name Akt esi'r 15Ai - SS 12 <br /> Phone <br /> Address -3613 <br /> 1 A/ A 17 cc�� Cit DE <br /> i"� 010 � ('7 y <br /> Contractor's Name cs s' `�{// License war-IrPhoneAEf <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other Ll W <br /> s <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES/t2Z�_ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /t7) r CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEJU�PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation -� ? <br /> V Domestic/private Drilled Dia. of Well Casings" <br /> Domestic/public Driven Gauge of Casing !' <br /> Irrigation Gravel Pack Depth of Grout Seal .S <br /> Cathodic Protection � Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: /Lath <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE Gia. <br /> =�- (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY cJ1 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION pHASZ II FINAL INSPECTION p <br /> w <br /> INSPECTION BY DATE ,,/ e INSPECTION BY --- DATE <br /> 6/772M_ <br /> E H 1426 Rev. , 1-74 '' <br />