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C� SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 7-,,I, Y3 yJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued-,Z 7- 7 <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 ,S - 1-1f t <br /> CENSUS TRACT <br /> Owner's Name Phone 3 ZEEy <br /> Address City <br /> Contractor's Name O 4�'ifG� / �.mss License rf Phone, <br /> i <br /> TYPE OF WORK (Check) : NEW' WELL DEEPEN/ / RECONDITION /7 DESTRUCTION-/- <br /> ME <br /> PUINSTALLATION PUMP REPAIR::/ / v .,PUMP,�REPLACEMENT /-7Other / / n r c <br /> xk i <br /> DISTANCE TO NEAREST: SEPTIC TANK �SEWER LINES PIT PRIVY <br /> ~= SEWAGE DISPOSAI FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -'PRIVATE DOMESTIC WELL Za0- "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 <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: p <br /> PUMP INSTALLATION: <br /> Contractor J' � <br /> Type of Pump H.P. 1 <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth k <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health, Di.strict <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- 11 and notify them before putting the w611 in use. The above <br /> information is true t the est of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO INAL TNIQN. . <br /> SIGNED TITLE <br /> DRAW PL OT PLAN 'ON RE LRSE SIDE) " <br /> PHASE I <br /> FORDEPARTNENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY ? DATE f <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL'INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE S. Z-` " <br /> 3 76. M <br /> E H 1426 Rev. 1-74 .. ' <br />