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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f <br /> PFOF'.'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone : (209) 466-6781 <br /> EAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> t f/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> i (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 /> . <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION s- 46r n l v air. 1z CENSUS TRACT ' <br /> Owner's Name EFF1447—FA Phone 6 S4 <br /> Address e irverz r Cit J <br /> Contractor's Name L3 ense # zinc Phone 9-3 Kir <br /> cz <br /> TYPE OF WORK (Check) : NEW WELL / / -DEEPEN /_/ RECONDITION / / DESTRUCTION /_ <br /> ' PUMP INSTALLATION-= PUMP REPAIR/ / ' PUMP REPLACEMENT /7 <br /> Other <br /> DISTANGEJJO NEAREST: SEPTIC TANK '`: ;..,,SEWER LINES PIT PRIVY <br /> ` + y SEWAGE DISPOSAL FIELD *R CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL.-t. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF ,WELL GONSTRUCTION SPECIFICATIONS <br /> Industrialzt <br /> �" _ -- - " <br /> "Cable, Tool FDiaFo_f4Weli Excavation <br /> Domestic/private DrilledDi of Well Casing <br /> Domestic/public I Driven #"�G�auge of Casing.- <br /> OK Irrigation + Gravel Pack Depth of Grout-�Sea1 <br /> Cathodic Protection H4 afi Rothf'y--4.; �, Type of Grout } <br /> Disposal Other �-"`Other formatilon <br /> Geophysical � Surfac�Seal,_Installed-By_ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ° 415r 010 is . H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done . <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth, <br /> Describe Material and Procedure <br /> r <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 /> t <br /> WELL DRILLERS REPORTo the well and notify them before putting the .well in use.. Th_�e above <br /> information is t"kue eo the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTINGeAND AFINAI INSPECTION. <br /> SIGNED TITLE �sQ�.�-�.-�. p; <br /> (DRAW PLOT PLAN ON REVERSE SIDE) f <br /> FOR DEPARTMENT USE ONLYr <br /> PHASE I w <br /> APPLICATION ACCEPTED. BY> DATE /�� � <br /> ADDITIONAL.COMMENTS 4' I <br /> =r PHASE II GROUT INSPECTION PHASE JI /FINAI, INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE.- 7� j <br /> 1177 <br /> L' H 1426 Rav_ 1-7G � <br />