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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0_R.OFFICE USE: �� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) : 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> -772,0 9 - e-� ' , (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 /> JOB ADDRESS/LOCATION <br /> 1�'Zl f400' Z-A 7-4,y CENSUS TRACT 417--,r7p-0/ <br /> Owner's Name7 �Phot�1 <br /> Address City . <br /> Contractor's Name License #.� Phon <br /> TYPE OF WORK (Check) : NEW WELL /P---DEEPEN / / RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other -- <br /> DISTANCE 'TO NEAREST: SEPTIC TANK SEWER LINES IT PRIVY <br /> SEWAGE DISPOSAL; FIELD CESSPOOL/SEEPAGE PIT OT R <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WEL <br /> INTENDED USE TYPE OF W LL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing 5-e (glif <br /> rigation 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 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /7 State Work Done <br /> a. <br /> DESTRUCTIIN 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, Twill 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 ben of my knowledge and belief. I WILL CAL FOR A GROUT INSPECTION <br /> PRIOR TO G: G AND A FI INSP CTE0.N. <br /> SIGNED -a 4A <br /> TITLE + ` ol.� <br /> (D PLOT PLAN ON REVERSE SIDE) <br /> 7PSE7 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE G. <br /> X21 — <br /> E H 1426 Rev. 1-74 � 1177 2M <br />