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SAN JOAQUIN LOCAL HEALTH DISTRI'rrr <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. 7 ' <br /> 01 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued JAN isin <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 / 6 Q .� /(/ _ CENSUS TRACT <br /> : Owner's Naga Phone 34y- 9,�J� <br /> v -- <br /> Address _ err. . LCity _ <br /> Contractor's )slams �/4License ll��yOb' Phone <br /> TYPE OF WORK (Check): NEW WELL L DEEPEN /� RECONDITION / 7' DESTRUCTION /7 <br /> PUMP INSTALLATION f�PUMP REPAIR /—/ PUMP REPLACEMENT <br /> Other L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE: PIT _ _ OTHER <br /> PROPERTY LINE - PRIVATF. DOMIsST1C WELL _ PUBLIC DOMESTIC WELL <br /> INTENDED USE T11PE OF WELL. CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation y�� <br /> Domestic/private Drilled Dia, of Well Casing &'I <br /> Domestic/public Driven Gauge of Casing <br /> _ X Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Crout \ <br /> Disposal Other Other Information (V <br /> Geophysical Surface Seal Installed By: Cj. 2V <br /> PULP INSTALLATION: Contractor <br /> Type of Pump T.�rbi,Yp H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /7 State Work Done <br /> DESTRUCTION OF 4ELL: 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 best of mXj&aQwlcdge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO Gt22WC 4AP CTIUN. -- ---- — <br /> SIGNED _ TITLE ,�_`,�,�t <br /> (DRAT: PLOT PLAN ON REVERS_EIDE)__ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . � ' Q DATE <br /> ADD.TIONAL COMMENTS: '— <br /> PHASE II GROUT INSPECTION PHASE /FINA INSPECTION <br /> INSPECTION BY _ DATE INSPECTION B � ATS: <br /> 11 1426 J'.,v. 1-74 r) o/77 2M <br />