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• SAN JOAQUIN LQLAL HEALTH DISTRICT <br /> FOE'`OFOCE USE: <br /> 1601 E. Hazelton.Ave. , Stockton, Calif. ' <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR -PUMP PERMIT Permit No.' <br /> � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,,�g-7�7 <br /> Lpplica�ion (Complete In Triplicate)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 of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ] - Q CENSUS TRACT <br /> - <br /> Owner's Namet <br /> LGU Phone <br /> Address �Q `(;[ Q City c , <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL ITT' DEEPEN '/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION --/PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 7< SEWER LINES PIT PRIVY ` <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER WeLj_ 240 f <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 ��•• — . <br /> /private Drilled Dia, of W�11 Casing <br /> Domestic/public D3rive.n Gauge of Casi'ngv.„r <br /> Irrigation f ti <br /> g Gravel' Pa�.k �.� . Upth• of Grout-Seal <br /> Cathodic Pro tec tion Rotary <br /> `1� F i "Type of Grout <br /> Disposal Other t? ,•. Other Information - <br /> Geophysical Surface Seal Installed By' <br /> PUMP INSTALLATION: Contractor <br /> :i Type of Pump 07” Ax H.P. +' <br /> PUMP..,REPLACEMENT: �,c� • <br /> x / / State Work Done <br /> 4D. <br /> PUME' .REPAIR:" State Work Done IJVI <br /> DES TRU TU '`OF WELL: Well Diameter �1[ Approximate Depth <br /> De cribe Material a rocedure <br /> / cel/fir <br /> I liere3iy�_agree to comply with all laws nd regulation of the an oaquin Lo " 1 Health strict <br /> and the Sate 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' s <br /> WEI;L-DRILLERS REPORT of the well and notify them before putting the wellin 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 G OUTING AND FINAL SPE T <br /> SIGNED ` TITLE <br /> D W P T PLAN ON RE RSE SIDE <br /> FOR REPARTMENT USE ONLY <br /> PHASE I 6 <br /> APPLICATION ACCEPTED BY DATEV1_ <br /> ADDIk,1ONAL COMMENTS: <br />` PHASE II GROUT .INSPECTION <br /> PHA � I I N #.INSPECT N <br /> F <br /> INS, CTION BY cp BATE 1 INSPECTION BY DATE j, <br /> I ItH 1426 Rev. 1-74 _ Gc�r. ' �l�� f9��,/ ��,..�.' i X77 <br /> 2M <br />