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SAN JOAQUIN LOCAL HEALTH- DISTRICT a <br /> FOR OFFICE US !; 1601_ E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ] <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /1k 'la <br /> i� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Y2?ZjD . ' <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 /> , .� . . n h <br /> JOB ADDRESS/LOCATIONS �*-' d ; CENSUS TRACT <br /> /J <br /> Owner's Name ; ry , 33 Phone 5�'6�: O Or <br /> Address City <br /> Contractor's Name License 4y'�2,373 Phone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN/ / RECONDITION /-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR-lo - PUMP REPLACEMENT /_7 <br /> Other J-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY ^ `. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER y ' <br /> PROPERTY LINE .-- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL__== ` + <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation <br /> Industrial i; � <br /> Domestic/private .� Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation j� Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal �I Other Other Information <br /> Geophysical ! Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> ,Type of Pump . H.P. <br /> PUMP REPLACEMENT / / State Work Done. <br /> PUMP .REPAIR: j 'State Work Done a <br /> DESTRUCTION OF WELL: Well Diameter ', Approximate Depth <br /> Describe Material and Procedure <br /> io <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 /> I� WELL DRILLERS REPORT of the well and_n tify them before putting the..well in use. The above <br /> information i true toj°the est of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION. <br /> PRIOR TO GROMNCeIAND NAL INSPE ION. <br /> SIGNEDTITLE <br /> u W. PLAN ON REMSE S IDE <br /> ;? FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 64APPLICATION ACCEPTED BY �` � 11; t,P DATE Z <br /> ADDITIONAL COMMENTS: 1! <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION . <br /> INSPECTION BY i DATE INSPECTION BY�. e--- DATE r �G ✓ <br /> E H 1426 Rev. 1-74 <br />