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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. f� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. V_/a q0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l0 `&-77 <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/ �� � lV / �jy�,� , �4' CENSUS TRACT <br /> Owner's Name I Nt��y„� f4 Phone <br /> Address S 4_e City <br /> Contractor's Name rvt� r T.� License 0-b7XYZPhone3f�3?! <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMEN /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL IELD CESSPOOL/SEEPAGE PIT OTHER �(� <br /> PROPERTY LINEWRIVATE DOMESTIC WELL CI"PUBLIC DOMESTIC WELL `�) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION � , <br /> Industrial Cable Tool Dia. of Well Excavation - K� <br /> Domestic/private X' Drilled Dia, of Well Casing (i <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal --�1n:) /od-:- <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 .3 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / 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 kno a ge elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTI <br /> SIGNED zol"I <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEP NT USE ONLY <br /> PHASE I r / <br /> APPLICATION ACCEPTED BY �cJ DATE / <br /> ADDITIONAL COMMENTS: <br /> P-HASE 41 GROUT INSPECTI N P I/FINAL INSPECTION <br /> 'INSPECTION BYDATE 'b INSPECTION BY DATE <br /> -- <br /> E H 1426 Rev. -1-74 <br />