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I�@e SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> FOE OFFI jj:USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ' <br /> IM APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /L-7- 7,6 <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 is made in compliance with San Joaquin <br /> County Ordinance No. 1$62 and the Rules and Regulations of :41g�p <br /> Joaquin Local Health District. <br /> JOB ADDRESS��LOCATION 2--0-6 Z s CENSUS TRACTZj <br /> ' I <br /> Owner's Name Q� Phone { <br /> Address �(?c� arra�. City Gid ' <br /> Contractor'Is Name License # 7�]-Thl one 6 �� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/fY RECONDITION / / ." DESTRUCTION /_7 f <br /> PUMP INSTALLATION / / PUMP REPAIR � PUMP REPLACEMENT /?. <br /> Other <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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domes, is/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Catho6ic Protection Rotary Type-of Grout <br /> Disposal ' Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> 11. COK <br /> PUMP INSTALLATION: Contractors 1.c4 N <br /> Type of Pump H.P. <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 a <br />.,- WELL DRILL>:RS 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 GROUTING AND A YINAL INSPE N. <br /> SIGNE ITLE 4 t <br /> jE. D 'L°T PLAN 'ON RE SE SIDE} `" <br /> j DEPART NT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCE B DATE <br /> ADDITIONAL. COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS A•- .II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE r # <br /> E H 1426 Rev. 1-74- <br />