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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ,OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ' Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . 17 <br /> .(Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> rind/or install the work herein described. This application is made in compliance with San Joaquin <br /> , County Ordinance Na418,N <br /> and the Rules and Regulations of the San Joaquin Local Health District:. <br /> gr_� �", ems: 2S-amu �(o <br /> JOB ADDRESS/LOCATION LL,LGL,"F 7 D I CENSUS TRACT <br /> Owner's Name �5 D� fj � '© Z-L/ Phone —J03-5 -3Z_5' <br /> Address City / <br /> e <br /> Contractor's Name S 1//W VAI P e�O License#POS3 }Phone , 4 -j V3 <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN /7 RECONDITION 1-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /? PUMP REPLACEMENT 17 <br /> Other %// <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY J <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 az 'y <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> ✓" Irrigation i. Gravel- Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information . . <br /> Geophysical A Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 4l"., R.P. <br /> .PUMP REPLACEMENT: . / / State Work Done <br /> PUMP REPAIR: / / State Work Done <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 /> information is true to- the-best-of- my.-knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO 9LOUTING AND A FINAL INSPECTION. ! <br /> SIGNED TITLE <br /> c DRAW PLOT PLAN ON REVERSE SIDE <br /> FO& DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE ' <br /> ADDITIONAL CONSENTS: <br /> r� <br /> PHASE IIROUT INSPE N PHASE 1117F AL SPB ION <br /> INSPECTION BY INSPECTION BY DATE 4 O7,? <br /> E H 1426 Rev. 1-74. r � h/75 2M <br />