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_ SAN JDAQUIN LOCAL HEALTH DISTRICT <br /> FOF: OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. "] 7-25�hlo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> ----...__—_-- ��•�,2 � -. .. -. CENSUS TRACT <br /> P. <br /> Owner's Name ��0.r l�5- - _ dt 4 �-`�r3 ►� - ---- Phone <br /> Address r City o I <br /> Contractor's Name Name o 1 <br /> va License # Phone <br />' TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN './ / RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION 44/ . PUMP-$REPAIR / f PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST:- SEPTIC TANK SEWER LINES 'y 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> 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: / / State Work Done <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 true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />!PRIOR TO GROUTING AND A FINAL INSPECTION. <br />' SIGNED _R-.c TITLE , <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> tPHASE I i n <br /> APPLICATION ACCEPTED BY DATE, •'� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRD NSPECTION PHASE II/F AL INSPECTION <br /> INSPECTION BY � DATE INSPECTION BY �` ` DATE ;!y,/0C,/77 <br /> s <br />' /7 ' ` <br /> E H 1426 Rev. 1-74 <br />