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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORtnPPICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7&�- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z_26_,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 oZ 441 Al 1}•„ 4-c �-o'r l CENSUS TRACT <br /> Owner's Name M , Ciro we Phone <br /> Address 2 City <br /> Contractor's Name a License # Z&Z;j--Phone <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /-7 DESTRUCTION /—j <br /> PUMP INSTALLATION / / PUMP REPAIR /Y—/—PUMP REPLACEMENT /? <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> k 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 /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ge, H.P. 3' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: State Work Done .a� ;9 1092 <br /> It <br /> ,2ES-TRUCTION 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 thewell in use.. The above <br /> information is true to the best of my knowledge . nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FINAL INSP N. <br /> SIGNED r TITLE <br /> (D PLO PLAN ON ERSE SI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C , DATE <br /> ADDITIONAL COMMENTS:N S. <br /> PHASE II GROUT INSPECTION PBAK II FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> E H 1426 Rev. 1-74 1-74 2M <br />