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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOt•OFFICE USE: (j� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z2:Z43 aJ,9 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued g::l <br /> (Complete In Triplicate) <br /> Application is hereby made tol 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. 1562 and:�the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB aADDRESS/LOCATION U/s <br /> CENSUS TRACT <br /> Owner's Name I+ Phone <br /> ' Cit <br /> Address 2-366 y <br /> Contractor's Name (/,¢ License #16,2373 Phone] G 0�� <br /> i <br /> TYPE OF WORK (Check) ; NEW WELL/ / DEEPEN / / RECONDITION /~T DESTRUCTION /-7 <br /> PUMP INSTALLATION "/ / PUMP REPAIR 07PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE tISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <br /> PROPERTY. LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE x- , TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> .....Industrial. Gable Tool ... . .Dia. of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public Driven t Gauge of Casing <br /> Irrigation Gravel Pack ' Depth of Grout Seal <br /> Cathodic Protection Rotary I Type of Grout <br /> Disposal :a Other Other Informationf. <br /> Geophysical ,, ,_Surface Seal Installed By: <br /> J <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump i H.P. 1 <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 <br /> WELL_DRILLERS_.REP.ORT.-of--the_..Well,.and_notify.-them before putting the .well in use. The above <br /> information is true to t best o my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO IN AND NAL IN ECTION. <br /> SIGNED TITLE <br /> W T T PLAN 'ON REVERSE SIRE) <br /> FOR,DEP TMENT USE ONLY <br /> PHASE I i r <br /> I APPLICATION ACCEPTED BY t DATE <br /> i ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY . . . DATE INSPECTION BY DATE —7 <br /> 3/76 <br /> E H�'1426 Rev. 1-74 . <br />