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SAN JOAQUIN .LOCAL HEALTH DISTRICT <br /> FOE„OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7L.3��y� <br /> THIS PERMIT EXPIRES 1 YEAR F'RON DATE ,ISSUED Date Is ued <br /> s �Z � <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 /> JOB ADDRESS/LOCATION m t/ -_A/ 4-, foe W -f Fit e CENSUS TRACT <br /> / N4� r_� - Phone , i <br /> Owner's Name �'� , <br /> ,�"/G 'w t ,� LJ a <br /> Address � ' . city , <br /> Contractor's Name „)mb/ License `. 19 74%C�Phone ' -7(e <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION / DESTRUCTION /7 <br /> PUMP INSTALLATION "/ / PUMP REPAIR -/x-7—pump REPLACEMENT /7 i <br /> Other /7 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> E SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL` PUBLIC DOMESTIC- WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS. f <br /> Industrial Cable Tool Dia. of Well'Excavation <br /> Domestic/private Drilled Dia. of Well Casing i <br /> Domestic/public' Driven Gauge of Casing <br /> Irrigation Gravel Pack- Depth of Grout Seal � <br /> Cathodic Protect'ion -'Rotary Type of Grout ' <br /> ,`Disposal °` Other Other Information - <br /> Geophysical Surface 'Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of H.P. 4" <br /> PUMP REPLACEMENT: ' <br /> / / Stare Work Done- <br /> . <br /> PUMP REPAIR: /jC/ State -Work Done G/1�ru�ra - aC ho <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure <br /> 1 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 knedge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO .G OUTING 'AND A PIN PE IO . <br /> SIGNED o,) TITLE ' <br /> V - (DRAW PLOT PLAN O REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I <br /> APPLICATION ACCEPTED BY DATE - --�e . <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /r <br /> v <br /> E H 1426 Rev. 3-74 <br /> 4/-75-- - - <br />