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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE: ' f 1601 E. Hazelton Ave. , Stockton, Calif. <br /> `j <br /> Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit -No. ,773oy&) <br /> THIS PERMIT .EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .j- �7, <br /> a (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> f and/or install the work herein described. This application is made in compliance with San Joaquii <br /> County Ordinance No... 1862 and the Rules and Regulations of :the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name . - a <br /> / Phone ' -S-42Y <br /> Address _122, 1° <br /> iery City <br /> Contractor's Name ' 67- 22L <br /> ZeAd"icense <br /> Phone'7_07— <br />' TYPE OF WORK Check): � r �' � <br /> NEW WELL J►- DEEPEN,,`I�� RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION / � cUMP RE-PAIR / /' PUMPOther t REPLACEMENT /7 <br />:DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES <br /> PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE. -- PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> IINTENDED USE TYPE OF . LL-1 CONSTRUCTION SPECIFiCATiONS - <br /> —.Industria]. able Tool Dia. of Well Excavation �r <br /> „_;Domestic/private Deiiled Dia. of Well Casing <br /> D mestic/public ` �- riven" Gauge of Casing <br /> ry Irrigation _ _ J. gravel- Pack De th of Grou e <br /> Cathodic Protection Ltatar p t Seal <br /> Disposal �- Type of Grout <br /> ---- _L__..,Other.� Other .Information <br /> ';Geophysical ' ` Surface Seal Installed B <br /> .. <br /> PUMP: INSTALLATION: Contracto - <br /> ;� Type .of Pump r P H.P. - <br /> 9 <br /> PUMP REPLACEMENT /% State Work Done <br /> t <br /> PUMP PEPAIR: - . State Work Done <br /> IDES.,TRUCTION OF WELL: Well. Diameter <br /> 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 an& 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 INSPECTION <br /> PRIOR TO GROUTING 'AND FINAL INSPE IO <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> AP ILP CATION ACCEPTED BY <br /> ADDITIONAL COMMENTS z DATE - Z 3~ �� t <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BYPHASE III FINAL INSPECT ON j <br /> _ DATE . INSPECTION BY DATE <br /> + E',Ii 1426 <br /> _�- — -'Rev. 1-74 I I.,.o ' <br />