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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ]FOS, OFFICE USE %" 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?Z-lg /z� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <br /> •�J`` (Complete In Triplicate) <br /> Application s /iereby 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_$an Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> a <br /> JOB ADDRESS/LOCATION 3 -7 51, / ►�iC' O/ZT G� /l°iMW7 CENSUS TRACT <br /> i <br /> Owner's Name ,�� L L �r(/Gts2T Phone , <br /> Address City <br /> Contractor's Name 717� ���`� ���74 C�f%L�� License # Phone <br /> i <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN /_7 RECONDITION /-7 DESTRUCTION ] /� <br /> PUMP INSTALLATION /� PUMP REPAIR/ / PUMP REPLACM49NT /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 W IL <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 /> 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 A.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -REPAIR: /_7 State Work Done <br /> T� 17 <br /> th <br /> CTION fftotco <br /> WELL; Well Diameter Apx,�imat� th Uw/C <br /> D s ribe terial and Procedure <br /> kAr <br /> by agrly with al laws and regulations of the San Joaquin Weal Heat istric <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 & <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 INSP CT N. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT INSPECTION PHAS"]M/Fae INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE a—T9_- <br /> 1/77_ - 2 <br /> E H 1426 Rev. 1-74 <br />