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ui SAN JOAQUIN LOCM..HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. ,. Stockton, Calif. <br /> I 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 <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 CENSUS TRACT <br /> Owner's Name Phone 9 / -- A2-2. <br /> Address7 <br /> city c A/1Co /11 <br /> Contractor's Name r License e,�IW�on � 2- (Y <br /> TYPE OF WORK (Check): _ NEW WELL�DEEPEN/-7 RECONDITION P� DESTRUCTION f <br /> t PUMP INSTALEATION /—/ PUMP REPAIR /-7 PUMP REPLACEMENT _/ <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 6 0 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE A- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial //R Cable Tool Dia. of Well Excavation <br /> - /l Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal S`D <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 '. �. f? State Work Done <br /> 'FRUCTION OF WELL: ell Diameter 6 Approximate Depth <br /> # �S Z escribe <br /> Material and Proced�e� -,OA <br /> Al <br /> I hereby agree to omply with all laws and regulations of the San Joaq n 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 GROUTIN D A FIN INSPECTION. <br /> &,Lz <br /> SIGNED/ lf-..._.. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE � [ <br /> ADDITIONAL COMMENTS: <br /> PRASE IT/ GROUT INSPECTIO PHASE III/FINAL INSPECTION <br /> INSPECTION BY ATE ! INSPECTION BY DATE /Z- 3- 71 <br /> E H 1426 Rev. 1-74 1-74 2M <br />