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i f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOK70FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 j <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 5 d3tJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued�d r7ld p <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 nd t ule nd 1 tia f Joaquin Lacal .Health District. <br /> � apo, � <br /> JOB ADDRESS/LOCATION 01. Q 1/J// ' f CENSUS:.TRACT <br /> Owner-Is Name Phone j <br /> Address 477.~-L,/-~ v/ City <br /> Contractor's Name LLicensofW s" Phone/2 <br /> TYPE OF WORK (Check) : NEW WELL /ET--DEEPEN -/_7 RECONDITION I_T DESTRUCTION / f <br /> AL <br /> PUMP INSTLATION /�t-�PUMP REPAIR ./� PUMP REPLACEMENT /7 <br /> Other / f --- <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 �1 <br /> INTENDED USE TYPE OF WELL . CONSTRUCTION SPECIFICATIONS <br /> Industrial moble Tool M Dia. of Well- Excavation ' <br /> mestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal f <br /> Cathodic Protection Rotary Type of Grout _ 2 s Y, <br /> Disposal Other Other Information �. <br /> Geophysical Surface Seal Installed By•` <br /> PUMP INSTALLATION: Contractor <br /> . Type of Pump H.P. <br /> PUMP REPLACEMENT: I / State Work Done <br /> PUMP 'REPAIR: /_7 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 ''constfuction. 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 GRO TIN AND A FINAL INS ION. <br /> SIGNED <br /> TITLE � <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> .. <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: . <br /> PHASE II GROUT INSPECTI N PHASE III FINAL. INSPECTI N <br /> INSPECTION BY C DATE Z-b INSPECTION BY DATE /b <br /> E H 1426 Rev. .1-74 s _ 4/75 2M I <br />