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�/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL;'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZA: 7S)' + <br /> THIS PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED Date Issued <br /> (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. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION o yep 1 - _�,�,ti, „moi CENSUS TRACT <br /> Owner's Naas h �°_ per., ._ ^� Phone <br /> Addres s -.1 D 2D 0 _ ri.4 City <br /> Contractor's Name License # LXM Phone <br /> TYPE OF WORK {Checkj: NEW WELL /_T DEEPEN '17 RECONDITION f7 DESTRUCTION /_7 <br /> PUMP INSTALLATION J / PUMP REPAIR PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 C <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 /> Type of Pump H.P. , <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / State Work Done. . ... •_ . ,..r . ,� ei @� <br /> DESTRUCTION OF WELL: Well Diameter 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 putting the..well. in.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 GR UTING 'AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVKRSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATA! 312 Y 7� <br /> k_ADDITIONAL COMMENTS: <br /> PRASE II GROUT IN$PECTIO PHA IIF NAL INSPECTI <br /> f INSPECTION BY DATE INSPECTION BY DATE <br /> i E H 1426 Rev. 1-74 - 4175 2M <br />