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. _ SAN JOAQUIN LOCAL HEALTH DISTRICVeF <br /> OF, OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. P4_ " h aw e-x <br /> Telephone: (209) 466--6781 P-Cri' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 27—IS-01 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1-lam- <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> band/or install the work herein described. .This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the R lee and Regulations of the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION — ----- CENSUS TRACT <br /> Owner's Name - <br /> Address �� — --- City !x <br /> Contractor's Name ( _ / /� License Phone -/ <br /> TYPE OF WORK (Check) : NEW WELL /xJ DEEPEN / / RECONDITION / / DESTRUCTION �— <br /> PUMP INSTALLATION../ / wiPUMP REPAIR / / Y PUMP REPLACEMENT <br /> DISTANCE TO NIAREST: , SEPTIC TALAR SEWER LINES �UO PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT-- <br /> OTHER _ <br /> PROPERTY I INE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE j -* .'- TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial f Cable Tool Dia_ . of WellExcavation " <br /> Domestic/private •, 'Drilled <br /> Dia. of Well Casing <br /> Domestic/public i Driven '"'"""Gauge of-Casing <br /> Irrigation Gravel Pack ;Depth of Grout Seal — <br /> Cathodic Protection 1_ Rotary »MType,of Grout <br /> —Disposal - <br /> - Other J Other Information <br /> Geophysical- <br /> Surface� Surface Seal Ihstalled By: llll <br /> PUMP INSTALLATION: c Contractor <br /> Type of Pump SteH.P. 1 <br /> PUMP REPLACEMENT: State Work Done <br /> G ewi. r_ �✓t Cf �"�`� <br /> a� / State <br /> PiT W -c-cMP REPAiR: / Work Done ��� <br /> 1). S-TRUCTION OF WELL: Nell Diameter Approximate Depth � � 0 <br /> I ulz- 6,,A PT1UP escribe Material and Procedure " <br /> fiI hereby agree tb 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 f my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR .TO_GR0.UTI D' A F-INAL_- 'T ON. <br /> SIGNED f'. TITLE- <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE -ONLY <br /> PHASE I . <br /> APPLICATION'ACCBPTED% BY � A_ �. DATE \. <br /> ADDITIONAL COMMENTS:' <br /> PHAS II GROUT INSPECTION P S I/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE' <br /> E H 1426 Rev. � 1-74 [ A fit_ D, ...J r - -A Bo, 17 IDM ,I <br />