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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> E <br /> FdF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone :. (209) ' 466-6781 <br /> APPLICATION FOR';-WELL CONSTRUCTION OR PUMP PERMIT Permit No. zz_w <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> Y (Complete In Triplicate) 20$- <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 /> �+ 'L o n? ,A Q a' ii SUS TRACT <br /> JOB ADDRESS/LOCATION S rz;I <br /> Owner's Name � Phone <br /> Address C7 City r <br /> ik <br /> Contractor's Name /z License Jt,?224Lq Phone <br /> i <br /> TYPE'�OF WORK (Check) NEW WELL% /PEN RECONDITION./� DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCEITO NEAREST: SEPTIC TANK I .SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL -FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL'S I-PUBLIC DOMESTIC WELL <br />� INTENDED USE TYPE <br /> OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation <br /># Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing s 6h _ &I AL11,g <br /> Irrigation Gravel Pack Depth of Grout Seal �+V <br /> Cathodic Protection Rotary Type of Grout E E M <br /> Disposal Other Other Information <br /> Ge{physical - F° Surface -Seal Installed By: M <br /> 4 . <br /> k PUMP INSTALLATION: f Contractors :��L� �� � � � - <br /> ` Type of.�Pump - � -- --7— <br /> ! PUMP REPLACEMENT. / / State Work Done <br /> PUMP.�.REPAIR: - _�:- 4 /._ Sta-te Wofk:Done <br /> } , <br /> DESTRUCTIION 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 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 "no't'ify them before putting the -well in use. The above, <br /> iinformat'ion is true to the be ; of m �� knbwledge. and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TI A FI INS <br /> , SIGNED " I r TITLE lv <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> /-7/7PHASE I <br /> APPLICATION ACCEPTED BY. DATE 5G <br /> ADDITIONAL COMMENTS: `I� <br /> PHA I GROU INSPECT 0 FHA E I /FINAL INSPECTI N <br /> INSPECTION BY ATE L-7:2 INSPECTION BY ATE <br /> R N 1IL26 Rav_ 1-74 •�y <br />