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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE 1601 E. Hazelton Ave. Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> (APPLICATION FOR WELL CONSTRUCTION ORPUMP PERMIT Permit No.15771 .1 <br /> �9 THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued <br /> �A (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> f 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 /> a" <br /> JOB ADDRESS/LOCATION S-6-61 Al S �� CENSUS TRACT <br /> Owner's Name <br /> �t <br /> Phone <br /> Address City <br /> Contractor Name jiA-11 � <br /> r • License �� 7Lhone CAC� 7�7� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR 0 PUMP REPLACEMENT <br /> Other — <br /> DISTANCE, TO NEAREST: SEPTIC TANK SEWER LTNES PIT PRIVY `- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER _ <br /> PROPERTY LINE _ PRIVATE DOMESTIC WELL PUBLIG DOMESTIC WELL <br /> INTENDED USE '` TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial j' Cable Tool Dia, of Well Excavation ( <br /> 1�. Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 0Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal I1 Other Other Information <br /> Geophysical Surface Seal Installed By: y' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: - �- <br /> State Work Dane <br /> PUMP .REPAIR: / / State Work Done <br /> zz <br /> DESTRUCTION OF WELL: Well Diameter _ f <br /> Approximate Depth <br /> Describe Material and Procedure -- <br /> u <br /> I hereby agree to complyiPwith 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 t`he well and notify them before putting the well in use.. . The above <br /> information is true to the best of my wledge an belief. I WILL, CALL FOR A GROUT INSPECTION <br /> PRIOR TO GWJjTI G AND FINAL, TIQS I <br /> SIGNED � ITLE <br /> ( W L T L ON RE SE SIDE) <br /> PHASE I <br /> OR DEPARTMENT USE ONLY <br /> F� ��� <br /> APPLICATION ACCEPTED: BY' 7 <br /> ADDITIONAL COMMENTS: �oot <br /> DATE l "/ <br /> PHASE II GROUT INSPECTION P SE II/ (NAL INSPECTION <br /> INSPECTION BY II DATE INSPECTION BY DATE O <br /> AlN <br /> E H 1426 Rev. • 1-74 it 2M <br />