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". 1 ,- ' �f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOOF � E USE: 1601 E. Hazelton Ave. ,. Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Stan 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 theSa Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION Z L L'z' ,/iy`1 •s •�-, CENSUS TRACT <br /> Owner's Name GG.2'.& Phone <br /> Address _ 573 �$ City <br /> Contracta,r's Name L.c� License f����hone i.-?,�7X <br /> TYPE OF WORK (Check) ! NEW WELL -/? DEEPEN /? RECONDITION /7 DESTRUCTION /-7 <br /> �/ <br /> PUMP INSTALLATION PUMP REPAIR/? PUMP REPLACEMENT <br /> Other /_7 <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 Cable Tool Dia. of Well Excavation <br /> -- k _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack. Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other, Information <br /> -Geophysical Surface Seal Installed BX: <br /> PUMA' INSTALLATION: Contractor <br /> Type of Pump44:312 OW ,� H.P. <br /> PUMP jk7 State Work Done <br /> PUMP 'REPAIR: <br /> State Work Dane <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 an 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 /> PRIOR TO G OU ING AND A FINAL INSP A <br /> SIGNED ✓ TLE <br /> DRAW P N REV SE SIDE <br /> PHASE I TOEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ATE <br /> ADDITIONAL:. COMMENTS: <br /> PHASE II GROUT INSPECTION P INSPECTION <br />� INSPECTIO14 BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 H/75 <br />