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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE• OFFICE USE: 01601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> A j/d31� <br /> i THI7-,7-S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is he y 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 ADDRE55/LOCATIONS CENSUS T CT <br /> + I Agk� <br /> �`► <br /> Owner's Name _ Phone <br /> cfp,Address '� 7 �� <br /> Cit <br /> Contractor's Name ' gin � Com' - "; License #2vz ` <br /> \p hone <br /> TYPE OF WORK (Check) : NEW WELL/R DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /AY—PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other V-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> �ct�., SEWER LINES PIT PRIVY =�-----. <br /> SEWAGE-DISPOSAL FIELDol� CESSPOOL/SEEPAGE PIT -,�� OTHER- <br /> PROPERTY LINE. - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL b� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ` Industrial Cable Tool Dia, of Well Excavation <br /> ` mestic/private Drilled Dia. of Well Casing if <br /> Domestic/public all Driven Gauge of Casing � v} <br /> Irrigation { (Gravel Pack Depth of Grout IL <br /> Cathodic Protection %, rotary Type of Grout <br /> Disposal Other <br /> Other Information <br /> Geophysical. pl ' <br /> s Surface Seal Installed By: �. <br /> PUMP INSTALLATION: 'Contractor . <br /> fTYpe�f Pump H.P. <br /> PUMP REPLACEMENT / /State Work Done <br /> . Y <br /> PUMP .REPAIR: / / State Work Dane! <br /> DESTRUCTION OF WELL: f Well Diameter t � 'F 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'we11;'I-will" furnish the San'Joa.quifl Local-Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> infor ion is true to the•best my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T UTING AND A F SPE ION, <br /> SIGN TITLE <br /> i (DRAW PT;7OT PLAN 'ON REVERSE S IDE ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: [ <br /> P I GROU �INSPECTIO PHASE <br /> gIjI/FINA1z7 iNSPECTIO <br /> INSPECTION BY' ATE INSPECTION BY IV0DATE <br /> E H 1426 Rev. 1-74 r .. . °. I' jBg-y � 1 f-7'7� 3/76 2M <br />