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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />r� FOF OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br />Telephone: (209) 466--6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br />y <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE, ISSUED Date Issued /�- <br />(Complete In Triplicate) <br />Application is herebyfmade 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 Joaquir <br />County Ordinance No. �i1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />JOB ADDRESS/LOCATION <br />Owner's Name <br />esF z n,,y i <br />i 17_ <br />5 )O4-70CENSUS TRACT <br />Phone AIS - .3,11 � : <br />Address <br />City <br />Contractor' s Names aN Joaquin Pump ��a <br />License irk 1�/037OPhone" i- y <br />TYPE OF WORK (Check): NEW WELL l I DEEPEN / % RECONDITION /_% DESTRUCTION /__] <br />PUMP INSTALLATION / PUMP REPAIR / / PU11P REPLACEMENT <br />Other <br />nTC'TAM(I.- <br />----- `)hVTiC TANS: 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 <br />Domestic/private <br />Domestic/public <br />Irrigation <br />Cathodic Protection <br />Disposal <br />Geophysical <br />PUMP INSTALLATION: <br />Cable Tool <br />Drilled <br />Driven <br />Gravel Pack <br />Rotary <br />Other <br />Contractor _ <br />Type of Pump <br />PUMP REPLACEMENT: /Mate Work Done <br />-PUMP REPAIR: <br />DESTRUCTION OF WELL: <br />Dia. of Well -Excavation <br />Dia. of Well Casing <br />Gauge of Casing <br />Depth of Grout Seal <br />Type of Grout <br />Other Information <br />Surface Seal Installed By: <br />State Work Done <br />Well Diameter <br />Describe Material and Procedure <br />H. P. <br />-t✓10 e?,f"Az 4,�—r7Lp <br />Approximate Depth <br />I 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 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 tolthe best of my knowled and belief. I WILL CALL FOR A GROUT INSPECTION <br />PRIOR TO GROUTING INA.I SP <br />SIGNED Sbte aac�rses� aip ao <br />TI'T'LE (Division of San Joa9ain Sulphur � <br />j (D P OT PL�AM REVERSE SIDE) ocrarriento t. <br />PHASE I <br />APPLICATION ACCEPTED BYI <br />ADDITIONAL COMMENTS.. <br />PHASE II GROUT INSPECTION <br />f�!NSPECTION BY DATE <br />E 11 1426 Rev. • 1-74 <br />DEPARTMENT USE ONLY <br />PHAS <br />INSPECTION <br />DATE ! Z f <br />INSPECTION <br />