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t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fd_R OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1`j -`� f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued D 117 <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 /> i <br /> JOB ADDRESS/LOCAL N ZI �� CENSUS TRACT <br /> Owner's Name : Phone <br /> 4 � I <br /> r <br /> i�r f <br /> Address City ✓��-,! dry <br /> r � , J , C 1� 1 i / License � J Phone <br /> Contractorrs Name �1v <br /> �J �� r ��-L:, <br /> TYPE OF WORK ('Check) : NEW WELL -/ / DEEPEN /_/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: ' SEPTIC TANK -SEWER LINES PIT`-PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER j <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 \ <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 �"� � �c�f _ , H.P <br /> i <br /> iPUMP REPLACEMENTv . 1 / / State Work Done ' <br /> PUMP '.REPAIR: ./ / State Work Done <br /> IDES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> M Descri.be; 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, 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 C bL FOR A GROUT INSPECTION <br /> tPRIOR TO GROUTING AND A FI AL INSPECTION. <br /> i SIGNED TITLE 7 <br /> ( (DRAW PLOT PLAN ON -REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I A <br /> APPLICATION ACCEPTED BY DATE &"-Z_3'-_77 <br />!ADDITIONAL COMMENTS: p SE I FIN INSPECTION <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> t <br /> _ 1177 _ 2M <br />