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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE 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 g-214-76 <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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCA T ON ,/�c � P,[. Q/LtlAd2 :� I" U°�h",ENSUS TRACT <br /> Owner's Name �� Phone <br /> '{n S <br /> Address �C City C&- f <br /> Contractor's Name �� �. License #&2_3'73 Phone:3C_ Y-S_ <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / 'PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / ' <br /> DISTANCE TO NEAREST: SEPTIC TANK € SEWER LINES r PIT PRIVY <br /> , <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 -:fide '` " Dia. of Well Casing <br /> Domemstic/public--- - - - -�Urveri -- =-Gauge of Gasirsg- <br /> - Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rory Type of Grout <br /> Disposal-, =' -�— Other Other Information <br /> Geopkaysical �� '`��� ' Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor . <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: m Ar State Work Done jox,41 <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 -he 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 he San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before pu ,ting the -well in use. The above <br /> information is true to thembest of. my knowledge and belief :. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G 4LM.D N INSPECT ON. <br /> SIGNED TITLE <br /> RAW PL T PLAN ON RE TERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTIOIT PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE p <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />