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} SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FSB OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. M-89 <br /> f THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued I -Z& j7 <br /> (Complete In Triplicate) <br /> Application is L reby 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 Re ulations of the S Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACTal- <br /> Q <br /> Owner's Name 1 Phone `* f <br /> rV ! <br /> Address O � .. City <br /> Contractor's Name(./ /cam License PYione <br /> r <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN'`/ / RECONDITION- / / DESTRUCTION-/_ <br /> .k.. PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> ' DISTANCE TO NEAREST: SEPTIC TANK tlSEWERILINES PIT PRIVY \ <br /> SEWAGE DISPOSAL FIELD- t CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL A <br /> INTENDED USE TYPE OF WELL )- CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic <br /> /publicDriven 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 S'u`rface Seal Installed BX. <br /> fE <br /> PUMP INSTALLATION: Contractor <br /> r <br /> - Type of Pump , .P. . T d <br /> PUMP REPLACEMENT: -T/. ..-State Work bone <br /> 3 <br /> PUMP .REPAIR: M/ ,/ " State Work Done <br /> `DES•TRUCTION:OF WELL:: Well Diameter Approximate Depth <br /> xDescribe 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 /> ka£ter 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 /> Iinformation -is- true to the best of my knowledge and belief. I WILL CALL FOR AIGROUT INSPECTION <br /> PRIOR TOG UTING AN NA INS E ON. <br /> SIGNED _ TITLE <br /> (DRAW.rPLOT PLAN ON REVERSE SIDE) <br /> OR .DEPARTMENT JJSD_ ONLY <br /> PHASE'"I <br /> tAPPLICATION ACCEPTED BY DATE2,/,/�/7 <br /> ADDITIONAL COMMENTS: R <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> kNSPECTION BY DATE INSPECTION BY DATE /- 7 <br /> 1/ <br /> E H 1426 Rev. 1-74 <br /> _ <br /> 77 2M <br />