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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0_E70FFICE USE: G 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _&5-,Z? <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X76 � <br /> (Complete In Triplicate) �� 1 <br /> Application is lie reby bade 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 /> OB ADDRESS/LOCATION 'ht. e fr/ G�a��` CENSUS TRACT <br /> i <br /> Owner's Name �� -c " -� Phone <br /> j <br /> Address 3 - � � �'-c.�m- city - � ; <br /> z <br /> Contractor's Name L_ezl . License #/�� 7 Phone <br /> r <br /> TYPE OF WORK (Check): NEW,WELL /7 DEEPEN '/? RECONDITION DESTRUCTION 17 <br /> PUMP'+INSTALLATION / / PUMP REPAIR-F<7 PUMP REPLACEMENTh /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY rn <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITOTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> -INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <br /> Industrial Cable Tool, Dia. of Well Excavation 11 <br /> Domestic/private f Drilled Dia. . of Well Casing �I <br /> Domestic/public Driven _- Gauge-df`Casing �I <br /> Irrigation Gravel Paco Depth of Grout Seal �I <br /> Cathodic Protection Rotary` ;v , Type of Grout <br /> Disposal Other Other Information it <br /> Geophysical - Surface Seal Installed 'B : ;M <br /> PUMP INSTALLATION: hContractor -'��"'� <br /> - _,.._.-......-T e_.of,Pump_ _ <br />' � r <br /> i PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: , State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate, Depth <br /> g T Describe Material a-ad 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 i 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 GROTITID4-ANR A FI NSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE �I <br /> ! <br /> PRASE I FOR DEPARTMENT USE ONLY <br /> � + � <br /> 4 APPLICATION ACCEPTED BY (3 • DATE '11 A-L 7 <br /> ADDITIONAL COMMENTS: /2-7 <br /> PHASE 11 GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> 1 INSPECTION BY DATE. INSPECTION BY DATE <br /> h/75. 2M <br />