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SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FOErOFFICE USE: 1601 E. Hazelton Avem. ,rStockton, Calif. <br /> Telephone: (209) 46.6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> i (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 Ordinan a No. 1852.and the Rules and Regulations. of the San Joaquin Local>Health District, <br /> � ��7o r''twtd S- S#6,6 <,.P Rives z QW, qac ,;: i E- <br /> JOB ADDRESS/LOCATION ► _M r e_wa O eP__ ,� - CENSUS TRACT - <br /> Owner's Name , s <br /> ,, Phone <br /> Address �-G.,. .: ,,,....�_ ' City <br /> Contractor's Name „J License # <br /> � p Phone � ©,r <br /> i <br /> TYPE OF WORK (Check): NEW WELL '/ DEEPEN -/-7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /_7PUMP REPLACEMENT. <br /> Other <br /> DISTANCE TO NEAREST: SEPTICiTANK SEWER LINES PIT PRIVY 0- <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 Q <br /> Industrial J Cable Tool Dia. of Well Excavation �� Q <br /> Domestic/private ri Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation 10 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 0 Rotary Type of' Grout , <br /> Disposal H . Other Other .Information <br /> Geophysical 'Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type �of Pump H.P. <br /> PUMP REPLACEMENT: / / State`'Wa k ebfie <br /> REPAIR: State Work Done <br /> ES.,TRUCTION OF WELL: Well Diameter- - 0 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-�S1ate of Calliornia'`ier'tai ing to or regulating well construction. Within FIFTEEN DAYS <br /> after of <br /> comp1] tionY '�Tyjwoxk�,on;�di new. well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS' REPORT of,,�the�well and notify ! them before puttin the .well in-use.. The above <br /> information°;is true �to`the'beat�of my”"knowledge and belief.- I WILL CALL FO& A GROUT INSPECTION <br /> I PRIOR TO GROUT G AND A N INSPECTION. <br /> SIGNED d47i TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE .ONLY <br /> PHASE <br /> APPLICATION ACCEPTED BY . <br /> DATE l <br /> ADDITIONAL iCOMMENTS: .;I` } <br /> PHASE II GROUT RSPECTION PHA S � I I FINAL INSPECTION <br /> INSP$CTION BYy .,. DATE INSPECTION BY V <br />'� 1426 Rev. 1-74 1-74 2M <br />