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/ SAN JOAQUIN LOCAL HEALTa DISTRICT <br /> FOP,e'OFFICE USE: 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 I YEAR FROM DATE ISSUED Date Issued. -,V-27 <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION R 8 CENSUS TRACT <br /> Owner's Name M DA14Z&dA> Phone — 7 6 <br /> Address City fEs <br /> Contractor's Name r License # o2y Phone <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN /7 RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /J PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other /J <br /> DISTANCE TO NEARESTt SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE --PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Q <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 /> Domestic/public 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: 47 <br /> State Work Done <br /> ES-TRUCTION 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-beat of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU NG AND A IN INSPECTION. <br /> SIGNED TITLE <br /> _ (DRAW PLOT PLAN ON REVERSE SIDEO�� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P E 11 GROUT INSPECTION PHAS III f NAL INSPECTION <br /> INSPECTION BY DATE' INSPECTION BY PATE 'S <br /> 1 E H 1426 Rev. 1-74 1-74 2M <br />