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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -TOT-"OFFICE USE: 1601. E. Hazelton Ave, , Stockton if. <br /> Telephone : (209) 46 l <br /> APPLICATION FOR WELL CON ION OR PUMP PERMIT Permit No. O S� <br /> THIS PE PIKES 1 YEAR FROM DATE ISSUED Date Issued 7 Z <br /> (Complete In Triplicate) <br /> Applicationis hereby to the San Joaquin Local Health District for a permit to construct <br /> and/or install th ork herein described. This application is made in compliance with San Joaquin <br /> County Ordin e No. 1862 and the Ies and Regulations of the San Joaquin Local Health District. <br /> Jo/ -� <br /> JOB ADDRESS/'rB�-I-QN B(jfGi� f.Y j t�t��G S �' r CE�NS TRACT <br /> v6L.Owner's NameS s- Phone <br /> Address City <br /> 1 ,ZeContractor's Name (���y � ��t..��+. ,�_5 License � V Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 — <br /> PUMP <br /> -7 _PUMP INSTALLATION /)" PUMP REPAIR / / � PUMP REPLACEMENT <br /> Other �` — — <br /> DISTANCE TO NEAREST: / SEPTIC TANK /tf/ SEWER LIDS 1190_ IT PRIVY <br /> SEWAGE DISP SAL IELD CESSPOOL/SEEPAGE PIT /�G -OTHER <br /> 7 PROPERTY LINE =PRIVATE DOMESTIC WELL'= PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation /2- "F«!�l <br /> Domestic/private Drilled Dia, of Well 'Casing <br /> Domestic/public Driven Gauge of Casing'. [Z1 <br /> Irrigation Gravel Pack Depth of Grout Seal `� � <br /> S �� �' <br /> Cathodic Protection � Rotary Type of Grout �? F- <br /> -Disposal Other Other Information <br /> Geophysical Surface Seal Installed -By: <br /> S <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump --,C 44 b el H.P. <br /> m. <br /> PUMP REPLACEMENT: / / State Work Done. <br /> PUMP .REPAIR: / / 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 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 INSPECTION. <br /> SIGNED TLE ! <br /> ( PL �PlwON REVERSE SIDE of <br /> FOR DEP TMENT USE ONLY <br /> PHASE I 44 <br /> APPLICATION ACCEPTED BY ,: DATE 7X2 <br /> ADDITIONAL COMMENTS: <br /> PHASE I GOUT INSPECTION P I/FINAL INSPECTION <br /> INSPECTION BY DATE %j-JLV)8%j—V)8INSPECTION BY DATE <br /> E H 1426 Rev. , 1-74 <br /> b,/77 2M <br />