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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOfi.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 3 4'7�1 <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 Rul and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONN-G"� �� "Ct c� ��` CENSUS TRACT <br /> Owner's Name Z, Phone <br /> A <br /> City <br /> Address �" G�s z�- �-- <br /> -C< <br /> Contractor's Name/ � ,��, � �-; `' -+��f License #,7e&ed� - Phone 's <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPE / / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION /PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �1 <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 <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 6fC� J <br /> Type of Pump t_ 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 CAL OR A GROUT INSPECTION <br /> PRIOR TO G UTING OLX INAL INSPECTION. <br /> SIGNED .m a TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY K DATE Z� <br /> ADDITIONAL COMMENTS: Ir <br /> PHASE II GROUT INSPECTION ►/ P S I FIN INSPECTION <br /> INSPECTION BY DATE f INSPECTION BY DATE - -� <br /> E H 1426 Rev, 1-74 <br /> 1777 <br />