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SAN JOAQUIN LOCAL HEALTH DISTRICT 64AILS Y <br /> FOL OFFICE USE: P 1601 E. Hazelton Ave. , Stockton, Calif. 0 a�n <br /> Telephone : (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2fk) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6`4f—J7 <br /> f Q� <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 Regulations of the San Joaquin Local Health District. ' <br /> A LF51� <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> I. <br /> Owner's NameJA Phone ll <br /> i <br /> Address City J��r+ <br /> ✓ <br /> Contractor's Name , <br /> License Phone S-2 3 <br /> TYPE OF WORK (Check) : NEW WELL r'DEEPEN / ,.RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION % s/ . PUMP REPAIR '/ / PUMP REPLACEMENT /7 <br /> Other / J z 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK 14F406 fiSEWER LINES/0 PIT PRIVY \\ '� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT Nja 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 �f I <br /> r <br />.._Dome s tic/public— ._._T _ .Driven Gauge of Casing _--•�-����_,�_�- �•: � <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of -Grout <br /> p '. <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Installed By,� E aadEl � <br /> PUMP INSTALLATION: Contractor <br /> _ <br /> Type of Pump, H.P. <br /> PUMP .REPLACEMENT: / / State Work Done b`''-iwi � €' <br /> PUMP -.REPAIR: . / / State Work Done i <br /> t <br /> DESTRUCTION OF WELL: - Well Diameter "` Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws acid regulations of the San Joaquin Local Health District <br /> an-dithe 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 wellin use. The above <br /> information is true to the best of my�knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />?RIOR -T0 GROU ANP,�g FINAL INSPECTION: . <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> DEP RTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: oe <br /> PHASE II GROUT INSPECTION/ PHASE /FIN INSPECTION <br /> INSPECTION BY DATE - INSPECTION BY, .! DATE l/�/Q---77 <br /> 11 / ry -Of <br />