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SAN JOAQUIN LOCM.`"HEALTH DISTRICT <br /> FOT:OFFICE USE: 1601 E. Hazelton Ave. , Stockton,- Calif. <br /> Telephone: (209) 466-6781 ••• <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> �V <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 the Rules and Regulations of the San 'Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION 77o7 CENSUS TRACT <br /> Owner's Name : I A Phone �0 �� 7 <br /> Address LSO _ <br /> Contractor's Name JLicense 0 2 p 2r hone 66 -069-L <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN 'f7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR -/? PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 7O SEWER LINES PIT PRIVY <br /> � SEWAGE DISPOSAL FIELD 7 Zt CESSPOOL/SEEPAGE PIT OTHER <br /> 6(7PROPERTY LINE - PRIVATE DOMESTIC WELL PIMLIC DOMESTIC WELL <br /> INTE14DED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled _Dia. .of Well Casing u <br /> Domestic/public Driven Gauge of Casing --- y C'_ - <br /> Irrigation Gravel Pack Depth of Grout Sear ►. <br /> Cathodic Protection _ Rotary Type of Grout I kd=&1&d.? <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'B : . . . <br /> PUMP INSTALLATION Contractor P v <br /> Type of Pump H.P. '�__ <br /> PUMP REPLACEMENT: . L/ State Work Done <br /> PUMP '.REPAIR: /7 .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 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 WTING AND AlIgAL INSPECTION. <br /> SIGNET? TITLE <br /> DRAW PLOT PLAN ON REVERSE SID_04=� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE_I- <br /> APPLICATION ACCEPTED BY DATE , <br /> ADDITIONAL COMMENTS-, <br /> PHASE II GROUT INSPECTION PHASE I I FII+iAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE TErte, <br /> E H 1426 Rev. 1-74 :; <br />