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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> sE: '1601 E. Hazelton Ave, , Stockton, Calif, 49 , <br /> ✓ Telephone: (209) 466/6781 � r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT eimit ^ivb. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued '`r��171 <br /> A (Complete In Triplicate) <br /> `cation is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ,or install the work herein described. This application is made in compliance with San Joaquin <br /> my Ordinance No. 1862 a h� les an Reg ns, a Sa Joaquin Local Health District. <br /> „OB ADDRESS/LOCATION CENSUS TRACT ' <br /> Owner's Name Phone <br /> Address 3.210Q- C.G City <br /> � <br /> Contractor's Naive 1 ��License .e Phone 61 <br /> TYPE OF WORK (Check) : NEW WELL / PEN /_/ -RECONDITION /_7 DESTRUCTION 1-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY W <br /> SEWAGE DISPOSAL.YIELD 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 /> ��emestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 2 <br /> AL- <br /> Irrigation Gravel Pack Depth of Grout Seal T � 1� <br /> Cathodic Protectionotary Type of Grout d <br /> Disposal Other Other Information' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <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 Jn Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting e .well in use. The ove <br /> information is a to the best my..knowledge and belief. I ILL CAL FOR A GR I SPECTIO <br /> PRIOR TO GRO AND A FINAL I E <br /> SIGNED TITLE <br /> DRAW <br /> POT PLAN ON RE FRSE SID i <br /> FOR DEPARTNENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL- COMMENTS: <br /> PHASE II G UT I SPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY / DATES INSPECTION BY <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />