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t160SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO - <br /> EjOFFICE USE: 1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 2 -&' <br /> THIS <br /> ` <br /> I <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued I-//- <br /> (Complete <br /> I1/-(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.: 186lJ2 and /the Rules and Regulations of the San Joaquin--Local Health District. <br /> JOB ADDRESS/LOCATION .sy� O UJ C&-,L �C(iQ CENSUS TRACT <br /> Owner's Name. G rV Ct"KC"-- Phone <br /> Address City / <br /> Contractora Name. License # OD7 Phone <br /> i <br /> TYPE OF WORK (Check): NEW WELL _/>7, DEEPEN/_7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMPINSTALLATION / 7 _ PUMP REPAIR /7 PUMP REPLACEMENT I_T.. <br /> Other <br /> 'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY j <br /> -SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER � I <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�T <br /> Domestic/private ' . IN <br /> Drilled Dia. of Well Casing � /2 <br /> Domestic/public Driven fi. Gauge of Casing <br /> Irrigation Gravel Pack Depth of'Grout Seal <br /> Cathodic Protection �_ Rotary Type of Grout' <br /> Disposal Other `Other Informaiio_n . <br /> Geophysical Surface Seal Installed BX: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.F. <br /> PUMP REPLACEMENT: / / State Work 'Done <br /> PUM *.REPAIR-. /7 State Work Done. <br /> 99 TRUCTION OF WELL: Well Diameter i. 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 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 puttingthe- well in-use. The above <br /> information is true to the-best of- my-knowledge and belief. I WILL CALL FOR A-GROUT TNS ION <br /> PRIOR TO GROUTING AND A FINAL INSPE ION. <br /> SIGNED m©j-r TITLE a7L" <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B . � DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE / 2-,�7 7 INSPECTION BY /j0G_ DATE /-/q - �_Z <br />� FI E H 1426 Rev. 1-74 1-74 2M <br />