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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh OFFI USE: V 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.JS-�aS^/o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .46-7-7S <br /> (Complete In Triplicate) (e - (/c-- ?-0 <br /> Application is hereby made to4 "7 <br /> 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 andlthe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ 4ht /� {� /� dj. ti[ ( �� AOa I CENSUS TRACT <br /> Owner's Name _�0 �e, I 4tk,J +0 Phone n! / <br /> Address ne S Ste» City UY�,r1f a / <br /> A-1 I <br /> Contractor's Name License ll, ). Phone 44)-7. <br /> U <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN -/-7 RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /%PUMP REPAIR / / PUMP REPLACEMENT /7 N <br /> Other /% 6N <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 lI <br /> Domestic/private i 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 <br /> Disposal Other Other Information — <br /> Geophysical Surface Seal Installed iv: <br /> PUMP INSTALLATION: Contractory T� eIll <br /> Type of Pump "Tip ✓ m H.P. <br /> PUMP REPLACEMENT: / / State Work Done - <br /> PUMP .REPAIR: /s7 State Work Done Llt,A-n� U-8 1410 <br /> pES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> n DescribeMaterial-,nd_Procedure <br /> I hereby agree-to•comply with-all•-iaws,and regulations of the San Joaquin Local Health District J <br /> and the State:of.,California:pertaining,to or regulating well construction. Within FIFTEEN DAYS " <br /> after completion of my work on anew well, Ilwillifurniah•the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the:wellCand-notifyjthem.before putting the well in use. The above <br /> information is [rue t'o'thebest of mywledge and belief. I WILL CALL FOR AGROUT INSPECTION <br /> PRIOR TO-G OUTING.ANDA�FINAL FNS_ I <br /> SIGNE \ ITLE /=yam <br /> TPLAN-ON= RSE SIDE <br /> -T -�;'�, \ FOR IDEPARTMENT USE ONLY <br /> PHASE.I <br /> APPLICATION <br /> 'ACCEPTED SY i DATE <br /> ADDITIONAL COMMENTS: -�fJr <br /> ,, PHASE II.GROUT INSPECTION PHASEII FINAL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE S { <br /> E H 1426 Rev. 1-74 <br />