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ri <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0S OFFICE USE: Imo' 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 1-2A-7 7 <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 Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations ofnthe San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION le, ?7"/z CENSUS TRACT <br /> f q <br /> Owner's Name G A0 Phone <br /> Address i _A6Le City T_ <br /> Contractor's Name License # jy'Zr Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /_� DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> DISTA9CE 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 S <br /> 1,-, Domestic/private Drilled Dia. of Well Casing <br /> - Domestic/public. . Driven Gauge of Casing <br /> f 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 pG <br /> Type of Pump H.P. �0 <br />. o <br /> PUMP REPLACEMENT: State Work Done d <br /> i PUMP '.REPAIR: / / State Work Done j <br /> �DESjRUCTION OF WELL: Well Diameter Approximate Depth <br /> T <br /> —� , .,._ PP P <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 GROUTIO AND A FINAL INSPE TION. <br /> SIGNED _ — - _ TITLE 77�� it <br /> (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / ZI/APPLICATION ACCEPTED BY X—5�' DATE t <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA.5§ II _ IFINAL INSPECTION/ <br /> INSPECTION BY DATE INSPECTION BY D AT Er IJ-ft L <br /> L L <br /> U77 2M <br />