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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE USE: ' �"" 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z?-M --1k) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued $=_j_1__2 <br /> ` (Complete In Triplicate) <br /> Application is Aereby"made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION D ;� f CENSUS TRACT <br /> Owner's Name ,, � , � � Phone Est- .2 D <br /> Address __. _ a ��6 win Citys� 1�,,, .,..,.__ <br /> Contractor's Name s License 4, :: 11 Phone e412_6/�e <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> D1,STANCE TO NEAREST: SEPTIC TANK /,Zp ` SEWER LINES PIT PRIVY -- <br /> SEWAGE DISPOSAL FIELD CES$POOL/SEEPAGE PIT OTHER --- <br /> PROPERTY LINE•?4PPRIVATE 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 /2 O <br /> _--6 Tr_'t atton Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout - <br /> Disposa'1 Other Other Information <br /> 19 d/�� <br /> Geophysical Surface Seal Installed B� 4r.45r,u <br /> PgT INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PURI$ :REPAIR: / / State Work Done <br /> •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 the es " ay,�cnowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO A FI Af 'L NS ION,-... <br /> SIGNED,---- <br /> TITLE _ J4_qlrgy <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE B-zG <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPEQMU P S /FINAL JNSPECTION <br /> INSPECTION BY DATE INSPECTION BY ITE <br /> E H 1426 Rev. 1 �i 1 ' 1/f77 - 214 <br />