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Cp � --- <br /> ef SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> yP`OfiOFFICE USE: 1601 E. Hazelton- Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> JOB ADDRESS/LOCATION %130VIF , CENSUS TRACT <br /> Owner's Name ��/V�Ga s ulA/�,v er" Phone 43s:� <br /> Address X301 I�is c.i'l�IV /��• �dx1�0 city <br /> i <br /> Contractor's Name a wAev- -,,*w License # Phone <br /> (!1 <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN '/? RECONDITION / DESTRUCTION / j <br /> PUMP INSTALLATION PUMP REPAIR'/-7—pump REPLACEMENT r7 <br /> Other L <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIVS PIT PRIVY <br /> SEWAGE DISP SAL FIELD /Vd CESSPOOL/SEEPAGE PIT . 0 OTHER <br /> PROPERTY LINE PRIVATEDOMESTIC WELL'_Q PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF LL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Did. of Well. Excavation <br /> Domestic/private Drilled Dia. of Well Casing tS <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection RotaryType of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By-: S yer <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ej H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP REPAIR:-- / 7 State Work Done <br /> DESTRUCTION 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 <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 belief. I WILL CALVI-0-R)AICIOUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITL <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Ly <br /> APPLICATION ACCEPTED BY C"10 r DATE 'Sf <br /> ADDITIONAL COMMENTS: -- <br /> PHASE Ii ROUT INSPECTION PHASE III F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 4/75 2M <br />