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` v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FUL OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /_9 js <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOS ADDRESS/IACATION A4 Jr_ f ny CENSUS TRACT <br /> 1 <br /> Owner's Name CSS �CyIty-r.� (J!®r e'; <br /> _ Phone <br /> Address _ Z a 6 ,Z,Cy &,/ City U daa <br /> Contractor's Name SfGw i License # 372_-'PhOne Y-7676 <br /> I a <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN /7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR b-] PUMP REPLACEMENT /7 <br /> Other — <br /> DISTANCE TO NEAREST: SEPTICiTANK 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 1.4. Cable Tool Dia, of Well Excavation- <br /> Domestic/private i Drilled Dia. of Well Casing \� <br /> Domestic/public f Driven Gauge of Casing v' <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout �l <br /> Disposal t Other Other Information <br /> Geophysical I _ Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor e� <br /> Type oIf Pump _ .e ✓ �� H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: /)C/ State Work Done 1;; e r aa-e <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth (} <br /> Describe Material and Procedure d0\ <br /> I hereby agree to comply withlall 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 to the best of-my.knowledge and elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO NG AND A FINAL INSPECTION. <br /> SIGNED �i TLE <br /> DRAW T PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> AP KATION ACCEPTED BY / % �� _ DATE �� S ?5 <br /> A IONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE Zi FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE- / _- <br /> jg <br /> E H 1426 Rev. 1-74 1.17C ou <br />