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f _ ' <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT _ <br /> FOWOFFICE 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.FROG[ DATE ISSUED` Date Issued r'�_%� 3 <br /> (Complete In Triplicate) <br /> Application is hereby made toIthe San Joaquin Local Health .District" fdr .a permit to construct <br /> and/or install the -work herein described. This application is .vaade 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 , , 1,v lev CENSUS TRACT <br /> Owner 9 s T Name , ��' f('1 C.t"_'S U ee C 'Al Phone - cZ33 <br /> Address + .. a 1 <br /> Sia �# city t SC ,19 <br /> Contractor's .Name License y Phone 93"kQ�?d] A <br /> TYPE OF WORK�(Check)i'lNEW WEtL-/_7 DEEPEN /? RECONDITION /_7DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> # — 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 C' , <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> Domestic/private A . Drilled Dia. of Well Casing 1 <br /> Domestic/public i. Driven ,419auge of Casing <br /> Irrigation' i Gravel Pack Depth of Grout' Seal, <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ' f Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contradtor _ �" P# A ' <br /> Type of Pump L H.P. <br /> i% <br /> 'r <br /> PUMP REPLACEMENT: S tate Work Dane 4 f.ea."Q&,e Ld i I`.�'� <br />' PUMP `.REPAIR: ""`'`,� ��--��.State�[+1ork Done - = --: - - - .F -_1-°s <br /> ESTRUCTION OF WELL: Well Aiameter pproximate Depth <br /> Desciibe Material and Procedure <br /> I hereby agree to comply withjall 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'we11;�I;wilL_furnish the Sau` Joaquin Local Health District a <br /> WELL DRILLERS. REPORT of the well and notify them before putting.the. well in.use.. The above E <br /> informatioiY'is truelto\the best -of,.'MY <br /> knowledgb._�zid' l;elief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROUTING' D`A. FIN . IN PECTION.. '�- <br /> SIGNED TITLE, <br /> (DRAW PLOT PLAN ON REVERSE-SID }>d <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I ; <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IIS PECT30N PHA AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE7�1 <br /> a _ _ <br /> 4- <br /> E H 1426 Rev. 1-74 1-74 2M <br />