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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> rp� + <br /> L11 � <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 �Jof the San Joaquin Local Health District. <br /> � 6th�✓ ryQ t �♦ <br /> JOB ADDRESS/LOCATION ^" CLQ/a //Lf <br /> CENSUS TRACT <br /> Owner's Name ��/�/ / /�/'/j1�'�' Phone 3 6 7 17 15 <br /> Address OSf S-3 I Wo J-Lo o _ City <br /> Contractor's Name �_ �, �p, S License #/b°3 X6,3 Phone <br /> J <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 LINFP'2 PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL C-3 . <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool- Dia, of Well Excavation <br /> X Domestic/private{ Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing fB Gk <br /> Irrigation Gravel Pack Depth of Grout Seal S 2, �i <br /> Cathodic P.r_otection -_ e Rotary Type of Grout �L- fi <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 /> j <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 Joaquin Local Health District a <br /> IWELL DRILLERS REPORT of the well and notify them before putting the -well in use.. The above <br /> linformation is true to the best of myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> .SIGNED � c7 �•pca�- .: TITLE C39e/'✓�/� it <br /> -_ <br /> "* '(DRAW PLOT PLAN ON -REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> iPHASE I ?r, <br /> (APPLICATION ACCEPTED BY DATE <br />�ADDITIONAL COMMENTS:.'`,1 F T <br /> PHASE IP GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z <br /> f <br /> E H 1426 Rev. 1--74 }f 0-•' � � <br />