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SAN JOAQUIN LOCA, HEALTH DISTRICT <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466»-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �S 1>1&). <br /> 7?- 4 6-P <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 th ules and Regulations of the San.Joaquin Local Health District. <br /> JOB ADDRESS: �7 ! <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> • C <br /> Address Cit <br /> Contractor's Name y` License <br /> TYPE OF WORK (Check) : NEW WELL. _W DEEPEN -/-7 RECONDITION -/_7 DESTRUCTION f7r r . PUMP` INSTALLATION. J�PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> / <br /> Other / 7—" <br /> DISTANCE TO NEAREST: SEPTIC TANK 4rLj - SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD4nQ_ —ftB8F@0V/1MEPAGE PIT-7 fl-OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL:—PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ., Cable Took. Dia. of Well Excavation.. <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public f Driven Gauge of Casing0 <br /> Irrigation Gravel Pack, Depth of,Grout Seal <br /> Cathodic Protection Rotary Type of Grout # <br /> Disposal Other Other Informations <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 <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 anew well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe -well in-use..—The above <br /> information is true to the-best -of my..knowledg and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING 'AND A FINAL INSPECTION. -0,007 <br /> SIGNED • °e TITL 012� <br /> (DRAW FrL0T PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /,//1? <br /> ADDITIONAL COMMENTS: <br /> PHA E II GROUT INSPECTION PHASE 111 FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3= .3 _7 7 <br /> II <br /> E H '1416 'Rev. 1-74 �n. w h/75 2M f <br />