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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOFirOFFICE USE: 1601 E. Hazelton Ave., ,Stockton, Calif. - r <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1;7 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In. Triplicate) t <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.. . Thia,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 /> JOB ADDRESS/LOCATIONCAM CENSUS TRACT - <br /> Owner"s Name ����/ �_ j � Phone 2)? � <br /> Adds e _ <br /> s City L �' �► <br /> s � <br /> Contractor's Name [,�.�_A7VMj!a5 fA16, License Phone 7_ <br /> - -1 <br /> { <br /> TYP3'OF WORK (Check): NEW WELL.,X DEEPEN /? RECONDITION /7 DESTRUCTION 17 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK P SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE-PIT OTHER <br /> PROPERTY LINE - PRIVATE BOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE'S : TYPE OF WELL <br /> I TYPE �,�,�'., CONSTRUCTION SPECIFICATIONS �.. <br /> Industrial - Cable Tool Dia. :of Well Excavation Z6f <br /> Domestic/private DrilledDia. Cof Well Casing <br /> Domestic/public Driven I Gauge of Casing A: <br /> _ Irrigation Gravel Pack Depth of Grout Seal -- <br /> Cathodic Protection Rotary ---T-Ype-of Grout <br /> Disposal Other Other Information <br /> Geophysical.. Surface Seal Installed B = <br /> PUMP INSTALLATION: Contractor.,-- , ;-�-q <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Done / '7l Egan <br /> PUMP REPAIR: ./? State Work'Dane <br /> ES-TRUCTION OF WELL: Well Diameter 1 _ � Approximate Depth <br /> �" w` escrib�;;Mater al-and=Proceduibr.�k <br /> I hereby agree to comply viith alllaws and regulations of the San Joaquin Local Health District <br /> and the State of-California-pertaitiing-.to--or--regulating-well c-onstructiori:Wit-hin FIFTEEN DAYS <br /> after completion of my work on a�rew wie11, I,will,�fuftish%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-bestwof-my- knowledge-and-belie.fA'GROUT INSPECTION <br /> PRIOR TO TING AND A INAL INSP ION: <br /> SIGNED . . TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE.ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYat_ DATE <br /> ADDITIONAL COMMENTS: <br /> PRASE- 11 GROUT INSPECTION PHASE TII FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE7'� <br /> E H 1426 Rev. 1-74 <br /> ... 1-74 2M <br />