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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0- OFFICE USE• 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. / <br /> A TZ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue <br /> #'' (Complete In Triplicate) <br /> -� <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 ari`d the Rules and Regulations of ..the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION (� � � / �2�� ^,� ��, CENSUS TRACT <br /> Owner's Name � �.lCS _—_--- _ Phone3/ � <br /> Address (o ,'f City <br /> Contractor's Name License 2_ul/ .Phone ]/a4ZJ, <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/ / RECONDITION /_7 DESTRUCTION /� •- . <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> -- <br /> Other _ <br /> DISTANCE TO NEAREST: SEPTIC TANK- :jiSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD -CESSPOO1;[SEEAAGESPIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL # _PUBLIC DOMESTIC WELL <br /> INTENDED USES` t TYPE OF WELL .-__.i��CONS-T-RUCTION SPECIFICATIONS <br /> Industrial ICable Tool Dia, of Well Excavation <br /> Domestic/private Drilled , �.-Dia. of Well Casing <br /> , Z Domestic/public 1 Driven Gauge'of, Casing <br /> Irrigation I Gravel Pack Depth of -Grout_ Sedl 10 <br /> Cathodic ProtectionlRotary Type_of_.,:Grout <br /> Disposal . Other Other InfA oration <br /> Geophysical "~ Surface-Seal Installed By_;__ dc�CfG <br /> PUMP INSTALLATION: Contractor . G <br /> Type of Pumper ti ."- r _ moi/ H.P. <br /> PUMP REPLACEMENT: / / State Work Done T _ <br /> PUMP .REPAIR: / / ,State Work Done i <br /> 44 �A i <br /> DESTRUCTION OF WELL: Wel1 -Diameter Approximate Depth <br /> Describe Material and,..Progedure _ <br /> k <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 /> lafter. completionof my wo a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS 'REPORT o the` 11 and notify them before putting the..well in use. The above <br /> information i the best of my. knowledge and belief. I WILL -CALL FOR A GROUT INSPECTION <br /> iPRIOR TO GROU G ri i <br /> SIGNED .�.�"� S <br /> -"TITLE'°"'..- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT-USE ONLY <br /> PHASE I .;. <br /> APPLICATION ACCEPTED'BY ) s a '\` . DATE IvC <br /> ADDITIONAL COMMEN S: <br /> P GROUT INSPECTION P II F NAL INSPECTION <br /> INSPECTION BY tDATE / INSPECTION BY DATE <br /> ]'I.Z � " r,2M <br /> E H 1426 Rev. 1-74 <br />