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r _ <br /> SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP .PERMIT Permit No. <br /> Q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued s3--7 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 _ d the Rules and Re tions of phe San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone 3TC <br /> Address c/ -Ei'' ` V'-"� " Ci <br /> Contractor's Name License hone <br /> TYPE OF WORK (Check): NEW WELL / .I� DEEPEN '/�I RECONDITION / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR-/ UMP 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 /> f 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 , H.P. <br /> i <br /> PUMP REPLACEMENT: . j—/ State Work Done <br /> L.�_W–.. . _ - — - - <br /> PUMP .REPAIR: / Sf' State Work"`Dori <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 /> r 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 A FINAL INSPECTION. <br /> TITLE <br /> SIGNED �r��p n��,✓ , ���. <br /> DRAW�PLOT' PLAN 'ON REVERSE SIDE) <br /> �:,�.., is <br /> ZLPART:MENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ,} '971-7Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA I / , NAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE 4(1sr <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 -. <br />