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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (2.09).,4466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No•,2 3Q / <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - �7 <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 Na. 1862and <br /> � the Rum and Re a ons of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 'T CENSUS TRACT <br /> Owner's Name G�� K Phone <br /> Address I �� Cit <br /> Contractor's Name License iZ4 -'_3 a3Pho 6 <br /> ,M <br /> i <br /> TYPE OF-WORK-(Check) : -NEW'WELL-/AL7- DEEPENd -/:77-RECONDITION"/_-/ DESTRUCTION�? �- <br /> PUMP INSTLATION REPAIR/ J PUMP REPLACEMENT /tom <br /> Other /_7 <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 , <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing O <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . P State Wor Dane <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 I, <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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING .AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW. Pf5T PLAN 'ON RE FRSE SIDE <br /> FOR DEP TMENT USE ONLY - <br /> PHASE <br /> NLY -PHASE I <br /> APPLICATION ACCEPTED BY DATE A/' 7r7, za, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN TION X PHASE III/FINAL INSPECTION <br /> INSPECTION BY DA INSPECT N BY DATE <br /> 3/7� 2P4 <br /> E H 1426 Rev. '1-74 <br /> '/ <br />