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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE .. 5 ; 1601 E. Hazelton Ave. Stockton Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 26- Vs- <br /> THIS <br /> -teTHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedz 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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION )"Qea [y�Q� G �.y�� CENSUS TRACT <br /> Owner's Name 01' Phone <br /> s <br /> Address City ..� <br /> Contractor's Name ��(�iyy� License # /A6a373Phone �{(4`•��6Z� <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION I I DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT LX� <br /> Other <br /> i <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 WELT. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial Cable Tool Dia, of Well Excavation /Z <br /> X Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor &AZZI A j <br /> Type of Pump .S4 H.P. <br /> S <br /> PUMP REPLACEMENT: / / State Work Done <br />"PUNfP .REPAIR `/:/ Siete-Wor-Doric <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 compleDf my work on a ne ell, I will furnish the San Joaquin Local Health District a <br /> WELL DRIL T of the well nd y them before putting the .well in use. The above <br /> informat'on o thebes w1 _I^WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T G D A NAT ON. <br /> SIGNED TITLE <br /> . (DRAW.PtOT PLAN ON RE FRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,? <br /> APPLICATION ACCEPTED BY � - DATE b -16 ,761 <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTT N <br /> INSPECTION BY DATE INSPECTION BY DATE - <br /> E H 1426 Rev. 1- 74 3/76 <br />