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E SAN JOAQUIN LOCAL HE"ALTH 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. 0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �d <br /> f (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. 1 862 and the Rules a��1 d Regt�1 ti n of the San Joaquin Local Health District. <br /> /fl ces a <br /> JOB ADDRESS/LOCATION s4�,V2 CENSUS TRACT <br /> Owner's Name �- Phone 9�"d� �®.: i <br /> i�S1 t c C mecca c <br /> Address . <br /> Contractor's Name ✓ , .y �( /t T_ License 2 lJ2-Rhone ( <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INS ALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 4jAj'-' SEWER LINES/ PIT PRIVY <br /> SEWAGE DISP SAL FIELD �CESSPOOL/SEEPAGE PI /�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 0 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ����/'}� 6—A/77 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 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 /> 1 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 T„cell'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 i true to t e beof my knowledge and , elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR N D FIN s 1 NSPECTION. <br /> SIGNED TITL _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLYAof <br /> PHASE I ,p <br /> APPLICATION ACCEPTED DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E III INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 714 y <br /> E H 1426 Rev. - 1-74 _- - �- -- - J <br />