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F SAN JOAQUIN LOCAL HEALTH DISTRICT A -� <br /> FOBrflF 'ICE USE: <br /> 1601- E.. Hazelton <br /> Ave. Stockton,, Calif. <br /> I Telephone: - ,(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z,6; yp <br /> j <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued7� 1 <br /> ' I (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 /> JOB ADDRESS/LOCATION <br /> S CENSUS TRACT <br /> Owner°a Nage , �L A w � PAL <br /> honekA-_-23o6, <br /> Address S' jr <br /> City 65 C A4BA/ <br /> Contractor's .Name , <br /> License #Q;790)0 Phone <br /> TYPE OF WORK (Check) : NEW WELL I / DEEPEN +-RECONDITION f7 DESTRUCTION <br /> I PUMP INSTALLATION /t/ PUMP REPAIR /-7 ;,P.UMP REPLACEMENT <br /> Other 7 3 .. <br /> DISTANCE TO NEAREST: SEPTIC TANK - <br /> k SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT;, - t OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL - :1, } CE}NSTRUCTION.. SPECIFICATIONS <br /> Industrial Cable Tool �. Dia. of Well-.Excavation . <br /> Domestic/private Drilled ^*�`Dia-.' ` <br /> Domestic/public . af�Well'Ca`sing` <br /> Driven Gauge of Casing <br /> Irrigation a Gravel Pack Depth of Grout Seal <br /> Cathodic Protection a Rotary Type of Grout �( - <br /> Disposal i Other_ Other Information <br /> Geophysical <br /> - Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> as _7 i H.P,• i <br /> PUMP REPLACEMENT: j State Work Done <br /> rTzl <br /> F _ <br /> PUMP REPAIR: ` - ;... . <br /> - - V i <br /> /� State Work Done �' <br /> ES TRUCTION OFF WELL: Well Diameter <br /> Describe Material— <br /> and Procedure Approximate Depth <br /> i <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 P <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 puttingthe.-well in-use.. The above <br /> information is true to the best-of my knowledge and belief. I WILL CALL FO A GROUT INSPECTION o <br /> 1111�PRIOR TO GROUTING AND A FI AL IN PECTION. <br /> SIGNED - � - _ <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATES 2 b <br /> PHASE II GROUT INSPECTION PI IN L INSPECTI i <br /> INSPECTION BY DATE INSPECTION BY �` <br /> � DATE <br /> E H 1426 Rev. 1-74 <br />