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w' T fffk <br /> r�7 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOSjOFFICE USE: ' ' '1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 �� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZLd Z 7_10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,�zt <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 16 -made in compliance with San Joaquin, <br /> County ordinance-;No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> F <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name .r Al. Phone 8 129 f429 4a <br /> Address City &,s- r <br /> Contractor's. Name _ v lLicense #p979.0A)Phone '$-.221)2 <br /> TYPE OF WORK (Check):: NEW WELL/-7 DEEPEN '/? ,RECONDITION J/_7 DESTRUCTION j <br /> PUMP INSTALLATION / / PUMP,.REPAIR � PUMP REPLACEMENT . / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWERLINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD "CESSPOOL/SEEPAGE PIT OTHER t <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL 11PUBLIC DOMESTIC WELL f <br /> INTENDED USE -11 TYPE OF WELL CONSTRUCTION SPECIFICATIONS � h <br /> Industrial Cable Tool Dia. of We'll Excavation " Li <br /> Domestic/private Drilled "- Dia. of Weil Casing <br /> Domestic/public . Driven Gauge of Casing i <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information v. <br /> Geophysical i Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT. _,. . / /,; '.State' Work Done ' <br />`"PUR'rREPAIR <br /> PES,TRUCTION OF WELL: Well Diameter a � Approximate Depth l <br /> r' Describe Material and Procedure it j <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 puttiing-the .well in-use.. The above <br /> information is true to the-best of my knowledge and belief. I WILL CALLFORjA GROUT INSPECTION <br /> PRIOR TO GROUT G ANDA AINAWNSPECTION. 11 <br /> SIGNED TITLE <br /> >.. (DRAW PLOT PLAN ON REVERSE SIDE <br /> OR TMENT USE ONLY <br /> PHASE I d <br /> APPLICATION ACCEP• ATE <br /> ADDITIONAL COMMENTS: <br /> U i PHASE II GROUT INSPECTIONII F AL INSPECTI N <br /> INSPECTION BY DATE INSPECi� DATE <br /> `� . ' E H 1426 Rev. .1-74 1-74L 2M <br />