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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7081OFFICE E 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. `S211'AJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ;2---3-7 <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 /> JOB ADDRESS/LOCATION � A,, L 'J -, CENSUS TRACT <br /> Y: <br /> Owner's Name /�'� t /1[o--�.T-� Phone 492`L►2 <br /> Address _ 0? i5 in Af g Af City /. 40 01 <br /> Contractor's Name �jf�,R 4-91 f /,d d c/ 4 ( ,f License #,.I moue rZ r 7 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION / 'DESTRUCTION fj <br /> PUMP INSTALLATION /� PUMP REPAIR 1-7—PUMP REPLACEMENT /7 <br /> Other /7 a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLICS, <br /> TIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial axle Tool Dia. of Well Excavation <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /40 <br /> ,__jC2rrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> DisposalOther Other Information <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: /7 State Work Done <br /> PEES-TRUCTION OF WELT.i We*"biamet*- 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 GROYZNGJLND A FINAL N ECTION. <br /> SIGNED TITLEI� t" <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ZZ?0- DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 CIO 2M <br />