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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. h -aZP <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -2L_7 <br /> (Complete In Triplicate) (b 2-,-- r+��-� <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 /> Is'-7>-q 10 .J:WA_ <br /> JOB ADDRESS/LOCATION Gf/,. yr.l� ` CENSUS TRACT <br /> Owner's Name i Phone 36 7(. 4L <br /> Address xoml Cityx L <br /> Contractor's Name License iILQi ZI Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /-" DESTRUCTION /_7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR : PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER h <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> N <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Z <br /> Dottestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven 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 Surface Seal. Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> ff <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP REPAIR: 45ir. State Work Done <br /> IV If <br /> DESr TRRUUCTION 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• est of my..knowl.edge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G AND A _FIjML INSP TION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO"PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT BYOL.5Fnl DATE <br /> ADDITIONAL COMMENTS. <br /> PHASE II GROUT INSPECTION PHAS I NAL INSPECTION <br /> INSPECTION BY DATEINSPECTION BY DATE <br /> i <br /> E H 1426 Rev. 1-74 4/75 2M•f <br />