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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FO . FICE USE: j/ 1601 E. Hazelton Ave. ,,Stockton, Calif. <br /> Telephone: (209),, 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -2"-?5 <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 Ordinan a No. 62 n the Rules and Regulations a San Joa uin Local Health District. It <br /> Ina r <br /> JOB X91&/LOCATI CENSUS TRACT } <br /> Owner's Name rl��r ,, a Phone <br /> Address -- City s <br /> 1 ' <br /> Contractor's Name ALicense k52��Phone �/-�Zfj <br /> TYPE OF WORK (Check)a NEW WELD, 'Jf.DEEPEN J..7- RECONDITION -./77,DESTRUCTION -/7 <br /> PUMP INSTALLATION PUMP REPAIR /7 PUMP REPLACEMENT <br /> OtherJ-7 <br /> f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT �OTHER <br /> 1 .1 --------.PROP-ERTY L-I-NE- -,PRIVATE--DOMEST.IC-WELT; --PUBLIC -DOMESTIC WELL <br /> INTENDED USE r TYPE OF WELL CONSTRUCTION, SPECIFICATIONS ki <br /> W i <br /> Industrial f 4-- -Cable Tool _ Dia. of Well'Excavation' <br /> I/Domestic/private frilled Dia. of Well Casing <br /> Domestic/public [-Y - Dtiven'­ Gauge of-/Casing 3 f <br /> Irrigation r--- Gravel- Pack �- Depth of Grout Seal, <br /> Cathodic Protection Rotary Type of Grout # ; I <br /> r Disposal ' ! Other 4 Other ,'Information': ' <br /> I Geophysical 1. 4 urfaee„Seal Installed By: <br /> I' PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done -` f <br /> PUHP'.REPAIR: J? State Work Done I <br /> 11 <br /> ES4RUC'T-I OF WELL a` .- -WL1-Diameter �'� ,` : _ = � - Approximate- Depth �- <br /> --- --Describe -Material-.and -Procedure- - - -- _ <br /> 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. 1 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 GROUTING AND A FINAL INSPECTI <br /> SIGNED TLE ` �- <br /> W 1sL0T ON REVERSE SIDE <br /> FOR D PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Y DATE 'fir 7 S <br /> i ADDITIONAL COMMENTS: l <br /> PHAS GROW INSPECTION PHASFIII7FINAL NSPECTION <br /> INSPECTION BY _ .� �' -�Nu—F . TION BY DATE <br /> 11 . ^E H 1426 Rev. 1-74 1-74 9M <br />