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9 a4 // 7, _11 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi+OFFICE USE: 1601 E. Hazelton Ave. , Stockton; Calif. - <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;F,, —�D [� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application 3s 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 incompliance with San Joaquin <br /> County Ordinance No.{ 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2—7 -!�7_ CENSUS TRACT <br /> Owner's Name f/LI�7 Phone <br /> Address . .,.�.----- City Q:7r <br /> Contractor's Name License # Phone <br /> i. <br /> TYPE OF WORT{ (Check): NEW WELL/`T DEEPEN/7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION /� PUMP REPAIR /7 CEME PUMP REPLAJ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ri <br /> SEWAGE DISPOSAL FIELD ,6/,,W CESSPOOL/SEEPAGE PIT �o,�� OTHER I <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' o PUBLIC DOMESTIC WELL <br /> .INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation p� <br /> 1 Domestic/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 /> I i <br /> Disposal ,, Other Other Information <br /> ormation <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 /> pESTRUCTTON OF�WELL: Well Diameter l Approxima a 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 1%-st of- my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO OUTING INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � <br />! . APPLICATION ACCEPTED BY DATE — <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA$ I INAL INSPECTIO <br /> i INSPECTION BY DATE INSPECTION-TY DATE (J 7 <br /> 'i E H 1426 # Rev. 1-74 /�`a^ <br /> /l.P"�-�^-� �-/�-s� ��'"a��? 'Ra... �I`��: 7 4 L�M <br />