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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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued UM177 <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 CENSUS TRACT 0(3--0090--Z <br /> L <br /> Owner's :Name Phone-36 311- �� 7 <br /> Address 3 7,K7 LJ. City -�1 <br /> Contractor's Name License jfl�2.3?3 PhoneAY-11-3f- <br /> TYPE OF 'WORK (Check) : NEW WELL/ / DEEPEN RECONDITION /_� DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION '0­PUMP REPAIR / / PUMP REPLACEMENT - /7 <br /> Other <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation O <br /> Domestic/private Drilled Dia., of Well Casing N <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 H.P. <br /> PUMP REPLACEMENT-. ' a 2- <br /> - - - - <br /> / % State Work Done T <br /> PUMP .REPAIR: / / 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 '-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 rue to the-best of my. owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G D Agj4LL INSPECT,60N. <br /> SIGNED TITLE <br /> nRAW f7 T PLAN_`ON RE RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I- DATE <br /> APPLICATION ACCEPTED BY �`� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT ON PHASE I_rII-// NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE `/f-� <br /> 3/76 214 <br /> E H 1426 Rev. 1-74 <br />