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SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. c <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 25(1_y6f_ <br /> THIS -PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a.23-y& CENSUS TRACT <br /> Owner's Name �� ti2,0 .i z e rL Phone 9,W- <br /> Address1.1 N LL City <br /> Contractor's Name. -✓ �✓ License QPhone r <br /> TYPE,OF WORK (Check) : NEW WELL/ / DEEPEN / RECONDITION L DESTRUCTION /_7 <br /> PUMP INSTALLATION j PUMP REPAIR/ / PUMP REPLACEMENT <br /> Otherj/ / <br /> DISTANCE TO NEAREST: SEPTICITANK 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 t Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ' I Rotary Type of Grout <br /> Disposal 1 Other Other Information <br /> Geophysical Surface Seal Installed BY: <br />'i . PUMP INSTALLATION: Contractor <br /> { <br /> Type of PuH.P. <br /> mp. scgz <br /> -- -. <br /> PUMP REPLACEMENT: !;State: Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES•TRUCTI`ON,� OF -WELL: - , Well;Diameter . ..Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with- all lavfs.. 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.ion 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 FOP, A GROUT INSPECTION <br /> ► PRIOR TO GROUTING AND F NAL INSPECTION. <br /> SIGNED . TITLE <br /> !101E& PEOT PLAN 'ON REVERSE SIDE <br /> FO ART, NT USE ON <br /> { PHASE I <br /> APPLICATION ACCEPTEDAL1/v�T DATE <br /> j ADDITIONAL COMMENTS: <br /> PHASE II GROUT.IINSPECTION PHAS IVVINAL INSPECTION <br /> INSPECTION BY iDATE INSPECTION B DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />