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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave., , Stockton, Calif. <br /> Telep'ho'ne: (209) 466--6781 <br /> 'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.'�'e- J, <br /> '� <br /> i <br /> ' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issueda 1/37/ <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. 18.62 dt`he Rules and Regula ions of the San Joaquin Local Health District. <br /> T T .Ile— 6n,-hbAV A�or Sa <br /> JOB ADDRESS/� Cfj ,� CENSUS TRACT " <br /> Owner}s Name /{ R6 ka'C/ _ Phone <br /> a <br /> Address N City <br /> f 4 j License J ZO&Phone ZIP <br /> Contractor's Name <br /> TYPE OF WORK (Check) : .,OEWyWELL DEEPEN / / RECONDITION"%/- ---DESTRUCTION. <br /> PUMP INSTALLATION W PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / A` � ��'.�-,r V,# <br /> DISTANCE TO 'NEAREST: SEPTIC TANK 11�7V SEWER LINES_. V <br /> SEWAGEDISPOSAL FIEZD � C SSP /SEEPAGE PIT f ? OTHER <br /> PC W <br /> PROPERTY LINE PRIVATE DOMESTIELL��'PUBLIC DOMESTIC WELL <br /> INTENDED USETYPE OF WELL CONSTRUCT'I0N SPECIFICATr NS <br /> Industrial ii Cable Tool Dia. of Well Excavation z-n `` <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing / <br /> Irrigation/ � ! Gravel Pack Depth of Grout Seal <br /> ` Cathodic Prot/ction -« Rotary i Type of Grout <br /> Disposal "-Other - - Other Information <br /> Geophysical `_ Surface Seal Installed-By: -, <br /> PUMP INSTALLATION.: "Contractor t 4 <br /> n Type of Pump �. H,P. <br /> PUMP REPLACEMENT: 1 / / State Work Done <br /> PUMP .REPAIR: ;: / / State Work Done <br /> DESTRUCTION OF WELL: ' Well.Diameter R Approximate Depth <br /> : Describe Material and Procedure _ <br /> � ; w <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 _ra.gulating well"construction. Within FIFTEEN DAYS <br /> after c mor c pletion of my; w k on new well, #I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use, The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECT IU <br /> SIGNED TITLE <br /> (DIntil"'PLOT L ON REVERSE SIDE) <br /> FOR DEP TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �/' DATE <br /> ADDITIONAL COMMENTS: it <br /> PHASEkII .GROUT INSPECTION P S I /FINAL INSPEC ION <br /> INSPECTION BY DATE _„-\1A-_j B . _ INSPECTION BY DATE <br /> F N 1426 Rav• . 1-74 <br />