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ll P ��3 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _09 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. NJ <br /> Z1�� <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' "th San Joaquin ; <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin LocaV Health District. <br /> JOB ADDRESS/LOCATION12 CENSUS TRACT <br /> Owner's Name Phone k3 - f_1111 Z3 <br /> Address 2l�r! City <br /> ,&,P� <br /> Contractor's Name C License # ox Phone 6%0-4,y-% <br /> TYPE OF WORK (Cheek): NEW WELL/� DEEPEN'-17 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTOLATION / / PUMP REPAIR /7 PUMP REPLACEMENT 1 } <br /> Other /7 <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/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 9'y <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:" _ ti �/ /. State Work Done <br /> PUMP-.REPAIR: Y /_7 State Work Done <br /> f <br /> ESTRUCTION OF WELL: Weil'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, 1'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 G TING AND A FINAL IjiSYECTION. <br /> SIGNED TITLE .- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY !r/G•. DATE .Z h <br /> ADDITIONAL COMMENTS_ : <br /> PHASE II GROUT INSPECTION PHAS 14 JFIVAL INSPECTION <br /> INSPECTION BY DATE ..INSPECTION. BY — -DATE 14-�,."-, <br /> i E $ 1426 Rev. 1-74 _ 374 2M <br />