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r SAN JOAQUIN LOCAL_ HEALTH DISTRICT <br /> FOF aFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ] FerAt4i„� f 17- <br /> k . <br /> �3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /yam <br /> ' (Complete In Triplicate) <br /> Application is Ytereby 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 /> dl-7U <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> (����G� /�� - C�E�L[.*t.f.!'t..���02e�i`�`_'����„F� �- �_ � <br /> l 0"Xtt� DPhone 599- 3 �7 <br /> Owner's Name ��f��C /� ��T�7��� ,_--- - . <br /> Address . �0 (. © I City A41rTr_rN _ <br /> Contractor's Name 22�/A/` STsc�'-Q�S. 'fLLfN�C� ;. License # ajj,0yjPhone S// 5 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <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 WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 13" <br /> Domestic/private Drilled Dia. of Well Casing =$11Q ffe <br /> Domestic/public Driven Gauge of Casing / <br /> Irrigation Gravel Pack Depth of Grout Seal 1 ; <br /> Cathodic Protection Rotary Type of Grout Z: <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> _ I <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 1 <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 /> 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 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED t LIn d a TITLE,. _ <br /> (DRAW PLOT PLANjON REVERSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION µ PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426ev. 1-74 <br />