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SAN JOAQUIN LOCAL. -HEALTH DISTRICT T .. <br /> FOk76FFICE 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 I YEAR FROM DATE ISSUED Date Issued 3 3=,,- <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. 18 nd Regulations of the San Joaquin Local Health District. j <br /> JOBrADDRESS/LOCATION 2- " `# CENSUS TRACT <br /> Owner's Name ork MalAw Phone ' <br /> Address Came-an- 1j Sjjlnt- <br /> City <br /> Contractor's NameGho -i4 <br /> License Phone Z <br /> ��� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN —/ RECONDITION /_7 /_71 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /7 <br /> Other / / T` ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES P,IT PRIVY <br /> SEWAGE DISPOS-AL-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 I. <br /> Domestic/public Driven ' -Gauge -of Casing, <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ii <br /> Disposal Other Other Informationz' <br /> Geophysical Surface Seal Installed By:- <br /> PUMP <br /> :PUMP INSTALLATION: Contractor <br /> Type of Pump zbjrbLnjP_ � H.P. <br /> LW <br /> PUMP REPLACEMENT: / / State Work Done $w <br />'-PUMP .REPAIR:--_. ""'"``'�!A' 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 bi6rrict . <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 Distri. Ct a. <br /> WELL DRILLERS REPORT of the well..iand notify.-them-before putting the. well in use. The above <br /> information a to the Best, of i my jkriowledge rand '' elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G A` FINAL INSPECTION. <br /> SIGNED .- TITLE <br /> `'(DRAW PLOTx'PLAN ON REVERSE SID ' <br /> FOR DEPARTMENT USE ONLY <br /> PRASE <br /> f APPLICATION ACCEPTED BY �1� -� DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE f--7T"7 r <br /> _ x 1/.77 . <br /> E H -1426 Rev. 1-74 <br />