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r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> q Telephone: (2091 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. was u/ <br /> !" THIS PERMIT EXPIRES 1 YEAR PROM.DATE 'ISSUED Date Issued { <br /> ii (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:I'with San Joaquin <br /> County Ordinance No. 1882 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONf I l C G CENSUS TRACT <br /> Owner's Name Phone <br /> r <br /> Address f r C City �G�lf , <br /> Ee f <br /> Contractor's Nam &Li2 A License <br /> TYPE OF WORK (Check): NEW WELL /Z?�_',DEEPEN '/?RECONDITION /_T '.DESTRUCTION f f <br /> PUMP INSTALLATION f7 PUMP REPAIR'/� PUMP REPLACEMENT <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK r,.' SEWER LINES — PIT PRIVY, <br /> SEWAGE DISPOSAL' FIELD j6-d CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY:LINE - PRIVATE, DOMESTIC WELL _ PUBLIC DOMESTIC-WELL v <br /> INTENDED USE N TYPE 0z WELL ' CONSTRUCTION SPECIFICATIONS <br /> s Industrial f g Cable Tool Dia. of Well Excavation i1 <br /> Il <br /> . P/'Domestic/private ; Drilled ' ---Dia.-,of Well. Casing .i <br /> Domestic/public il Driven Gauge of Casing <br /> Irrigation i w Gravel PackDepth of Grout Seal 5 <br /> IL <br /> Cathodic Protection Rotary t y .Type of Grout <br /> Disposal Other a Other Information . . ip <br /> Geophysical Surface Seal Installed By <br /> r <br /> f PUMP INSTALLATION: Contractor, AX j <br /> Type of Pump i r" H:P. <br /> PUMP REPLACEMENT / / State Work Done' <br /> PUMP :REPAIR: / J State Work Done" <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth . <br /> Describe Material and Procedure <br /> 1- hereby agree to comply with all ,laws and regulations of the San Joaquin Local Health District <br /> l and the State of California pertaining to or regulating well"constructi.oa. 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:YOR-A-GROUT INSPECTION <br /> PRIOR TO GR UTING AND Ali gIE4 INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSEa[- <br /> .FOR DEPARTMENT USE ONLY <br /> PHASE I h <br /> APPLICATION ACCEPTED BYDATE L-7k <br /> ADDITIONAL CO ;r- iM <br /> P INSPECTION S IIF NAL INSPEC'TIO <br /> INSPECTION BY i DATE C3 ± INSPECTION BY DATE <br /> `E H 1426 1-74 // F/w � � �'u'z i".�`� , `� "�t% '2N1 <br />