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" SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f <br /> FOS OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -353 ' <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <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 --y.,� CENSUS TRACT <br /> Owner's Name 1,4 <br /> �. Phone <br /> Address D - �.�_'11 -. k City <br /> Contractor's Name License #-�Ad �Phone <br /> I v,Jr—' <br /> E ' Z <br /> TYPE OF WORK (Check): NEW WELL /~T DEEP f RECONDITION /_� DESTRUCTION /_7PUMP INSTALLATION REPAIR PUMP REPAIR / / PUMP REPLACEMENT ' <br /> I Other ��-• <br /> DISTANCE TO NEAREST: SEPTIC _TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL . PUBLIC DOMESTIC 'WELT. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ICable Tool Dia, of Well Excavation. -� <br /> Domestic/private Drilled Dia. of Well Casing <br />! Domestic/public t Driven Gauge of Casing O <br /> i. Irrigation A Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal t Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> °PUMP INSTALLATION: Contractor 'P <br /> Type cif Pump H.P. f <br /> PUMP REPLACEMENT: State'-Work Done <br /> PUMP .REPAIR: / '/ State Work Done <br /> DESTRUCTION OF'WELLi 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-iof my work on a new well, I will furnishthe 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 />' informationIis .true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIO <br /> PRIOR TO GROUTING AN]?-\A FINAL INSPECTION. <br /> SIGNED - TITLE C .e <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FO EPARTMENT USE ONLY f <br /> PHASE I - <br /> APPLICATION ACCEPTED BY :DATE <br /> ADDITIONAL COMMENTS: :t <br /> k PHASE II GROUT INSPECTION PHA I AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> j - <br /> E H 1426 Rev. 1-74 1 f 7.7.. ` <br /> 21� <br /> E.. <br />