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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOP.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> I II r <br /> I! THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,-9 Z <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION !`: 'aop d e A 1l aJ mar a✓!rl xu4ENSUS TRACT <br /> Owner's Name �i cc-�� <br /> �0 0 � � Ja Phone <br /> t <br /> Address <br /> l�lf,-a City <br /> -- �-e <br /> Contractor's Name License # !f3)y,�hone <br /> TYPE OF WORK (Check) : !NEW WELL/ / DEEPEN/% RECONDITION /% DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /_ <br /> other / / -1 <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 <br /> Domestic/privatJ Drilled Dia. of Well Casing <br /> Domestic/public f Driven Gauge of Casing <br /> �e Irrigation : • ! Gravel Pack Depth of Grout Seal <br /> Cathodic Pr_otecti'on Rotary 1 Type of Grout <br /> Disposal Other t Other Information <br /> Geophysical ` Surface Seal Installed B <br /> PUMP 'INSTALLATION: <br /> (Contractor <br /> w IlType of Pump - r - F H.P. C <br /> PUMP REPLACEMENT: iw/ / State Work Done <br /> re <br /> PUMP .REPAIR: ' / State Work Done ' .c ,� 0 1 r f_ r <br /> IVV <br /> DESTRUCTION OF WELL: Well Diameter t _ �_._�• Approximate- Depth <br /> x':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 Sari 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 tothe best of.4_my knowledge-and belief. I WILL CALL FOR A GROUT INSPECTION <br /> '. PRIOR.TO GRO TING AND A' FINSECT`ION,. <br /> SIGNED _PA TITLE P"��{1 _ .•.. <br /> (DRAW P T,'PLAN ON ERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �j DATE <br /> ADDITIONAL COMMENTS: !I <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION ' <br /> INSPECTION BY :i DATE INSPECTION BY DATE <br /> yy� 7 <br /> E H 1426 Rev. 1-74 ,/' 177 M <br />