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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . Telephone: (209) 465-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 61 y <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/LOCATIONLower Sacramento Rd CENSUS TRACT <br /> Owner's Name Phone <br /> Address 10425 LoVer Sacramento Road City Stockton <br /> Contractor's Name lark Well & I; ui ment Co. License l 76602 Phone 462-5597 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDIT N / D STRUCTTON /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / P REPLACEMENT /_7 0 <br /> Other / / _41- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia. of Well Excavation 10 <br /> X Domestic/private Drilled Dia. of Well Casing 10 <br /> Domestic/public Driven Gauge of Casing 88 <br /> Irrigation - Gravel-Pack Depth of Grout Seal 50 <br /> Cathodic Protection �( / Rotary Type of Grout Cement <br /> ,XZDisposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> 3 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 the well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO UTING AND A FINAL NSPECTION. <br /> SIGNED TITLE I <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ^ j <br /> 'FOR DEPARTMENT USE ONLY <br /> PHASE I : . . <br /> APPLICATION ACCEPTED BYDATE 6�.9� 7A t <br /> kADDITIONAL COMMENTS: <br /> P PHASE II GROUT INSPECTION PHASE I /FINAL INSPECTION <br /> INSPECTION BY 1C DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 -- 1/77 - 2M <br />