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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR -OFACE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 27 11 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 <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 Regulation of the San Joaquin Local Health District. <br /> ` - �-� <br /> JOB �ADDRESS/LOCATION ��p f� � CENSUS TRACT <br /> Owner's Name C ,ll®r .o, C a., Phone <br /> Address 4—A-- &-a--'' d City - <br /> Contractor's Name License # hone _, - <br /> TYPEOFWORK (Check): NEW WELL/ / DEEPEN /_/ RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION / / : PUMP REPAIR%/ PUMP REPLACEMENT . -7 <br /> Other <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 /> Domestic/private Drilled Dia. of Well Casing - ' <br /> Domestic/public Driven Gauge of Casing =� <br /> Irrigation Gravel Pack . Depth of Grout Seal <br /> �`. <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 ­HAP. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /X/ • State-Work Done, <br /> f <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 /> i <br /> information is true to the-best 'of y knowledge and belief. ' I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND A ,FINAL- INSPETIO <br /> SIGNED 0a a.A TITLE ,� ,. r• <br /> (D W P OT PLAN ON MVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I GEOZZNSfECTION PHA I�MNAJ, INSPECTION <br /> INSPECTION.BY DATE INSPECTION BY DATE <br /> 1f77. _ 2M <br /> E H 1426 Rev. 1-74 - _ _ a <br />