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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOHjOFFICE USE: V/ 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209)` 466-6781 I <br /> 412 42� APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> y_/7G <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 34d1tA3# o an Joaquin Local Health District. <br /> JOB ANEW/LOCATION B'Y O ENSUS TRACT <br /> i <br /> Owner's Name 1. c �.f�,tt,p P_ �r0/!S _ Phone <br /> Address .3.?,3 's- <br /> Contractor's <br /> Contractor's Name �,,� 1,04 1License hone <br /> TYPE OF WORK (Check): NEW WELL 'W DEEPEN/7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /F PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other j/% <br /> DISTANCE TO NEAREST: SEPTIC TANK 4-SEWER LINES PIT PRIVY —� <br /> SEWAGE DISPOSE—FIELD /.SEEPAGE PIT �f'OTHER <br /> PROPERTY LINE --_PRIVATE DOMESTIC WELL -PUBLIC DOMESTIC WELLI� <br /> INTENDED USE TYPE OF WELL _..._.CONSTRUCTION SPECIFICATIONS w <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 /> Cathodic. Protection Rotary Type of Grout <br /> Disposal , k Other Other Information w <br /> Geophysical Surface Seal Installed By: <br /> t PUMP INSTALLATION: Contractor ,� � 6 4w S. :. <br /> E Type of•Pump..-q-�.,'. H.P. - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /? State Work Done <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 /> k 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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FI SPE <br /> SIGNED LE P <br /> IF -(DW OT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE 'ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION- BY DATE <br /> 4 E H 1426 Rev. 1-74 .1--74 2M s ,� <br />