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L SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi OFFIeE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ,,11.. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No,�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l <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. 186/2 and the Rule and Regulati of the Sa Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION < CENSUS TRACT <br /> Owner's Name Phone o 74 719 <br /> l _ 1 <br /> Address City -� <br /> Contractor's Name nse ' Phone <br /> IL 9 <br /> _ E 7 --72— <br /> TYPE <br /> JTYPE OF WORK (Check): NEW WELL L7 DEEPEN '/7 RECONDITION/? DESTRUCTION <br /> PUMP INSTALLATION ��-PUMP REPAIR'/� PUMP REPLACEMENT /7 <br /> Other /? <br /> DISTANCE TO <br /> NEAREST: SEPTIC TANK_ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER / <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC MgSTIC WELL_ „= N, <br /> INTENDED USE TYPE OF WELL ICONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> -Domestic/private 4--Drilled Dia. of Well Casing V <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal r <br /> Cathodic Protection L_-Rotary Type of Grout <br /> Disposal Other Other Information <br /> —Geophysical ,,.� <br /> Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> LAXt <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP :REPAIR: /7 State Work Done <br /> ESTRUCTION OF WELL: ell Demeter ApproxmssE€e° Depth <br /> escribe'X4erial 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 GROUTING AND FI INSPECTION. <br /> SIGNED Va,c TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /'- <br /> APPLICATION ACCEPTED BYDATE 1-77 <br /> ADDITIONAL COMMENTS: <br /> P S"6w:, <br /> INSPECT ON PHA E F INSPECTION <br /> INSPECTION B DATE -'7' INSPECTION BY DATE $'-/o --7 7 <br /> le <br /> 3& <br /> 01 <br /> E H 1426 Rev. 1-74'� 3� 2M <br />