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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF,;OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 11-11-7s— <br /> (Complete <br /> 1-11-7s(Complete In Triplicate) <br /> Application is hereby mase to the San Joaquin Local Health District for a permit to construct <br /> and/or install thework 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 ZZ -5-/ C7_1" r d1j Y49- CENSUS TRACT - <br /> Owner i s Name 7-1- Phone <br /> Address 1 F' PNJ' I/ City <br /> Contractor's Name 'L7 %nU Licensed hone <br /> TYPE OF WORK (Check): NEW- WELL /7 DEEPEN'/? RECONDITION /7 DESTRUCTION W <br /> _ PUMP INSTALLATION / / PUMP REPAIR IV PUMP REPLACEMENT /_7 <br /> ther <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (�1 <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 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 By: <br /> PUMP INSTALLATION: Contractor <br /> Tpe of Pump H.P. <br /> PUMP REPLACEMENT: L-4 State Worts Done <br /> xPUMP :REPAIR: State Work Don <br /> �- A � timate-Dept <br /> RES.TRUCTION-OF-WELLf! -JWel-l-Diameterh <br /> j 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 ;Fwork 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-j�the.best of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED )" . ''M TITLE l <br /> �j. (DRAW PLOT PLAN ON-REVERSE SIDE <br /> FORDEFMMIVNT USE ONLY <br /> PHASE I a <br /> APPLICATION ACCEPTED BY - DATE t - t�'7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTIO <br /> INSPECTION BY ��. DATE INSPECTONBY DATE 7 <br /> a 3l � � " <br /> �• ��� <br /> 1 E H 1426 Rev. 1-74i-7 4�4 G� 2M - <br />