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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601azelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. :Z Z14 <br /> THIS .PERMIT EXPIRES 1 YEAR .FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin. Local Health District f'or 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 Rgked R,Ad CENSUS TRACT <br /> Owner's Name Phone 's <br /> Address IT -72:7 64 ktk�eR-6 A d City Z/ A,1e1ePV <br /> i <br /> Contractor's Name llN`Oct?- �� �� ti/� ��I A^e License ;'x. 61 Phone <br /> r <br /> TYPE OF WORK (Check) : NEW WELL /^/ DEEPEN %/ RECONDITION / / DESTRUCTION /� <br /> PUMP INSTALLATION / PUMP REPAIR /�/ PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ _ SEWER LINES PIT PRIVY_jW <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT //t OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ____. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> � ' <br /> Industrial "� '"`"Cab.le`Tool"`_"�'��9Dia..__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 �/v®r�P a l3cp JL4 <br /> Q <br /> Type of PumpJ� ns E /t H.P. <br /> 1 <br /> PUMP REPLACEMENT: /L-/,-­-,St-ate"-Work DoneA /Cjj,2 "C " <br /> i <br /> PUMP .REPAIR:' / / . State Work Done k <br />' DES-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 Locall,'Health District a 1 <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 �. TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SID AJ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> r <br /> APPLICATION ACCEPTED-BY- "" o-- . DATE 5 �� <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION` ` �i , `. . PHAS I I/ NAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> b/77 _ 2M <br /> E H 1426 Rev- 1-74 �� <br />