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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOF, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Gcrt opo" 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/pr,*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 c9,? Sal— CENSUS TRACT <br /> Owner's Name Phone <br /> f (� <br /> Address - `�e 464 o-04- P City CJ �'\.. <br /> Contractor's Name License # /f:7;j Phone ' <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ I DEEPEN%% RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR /X/ PUMP REPLACEMENT /_7 <br /> Other <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 �n <br /> Domeseiclprivate Drilled Dia. of Well Casing VS <br /> Domestic/public •`Driven Gauge of Casing <br /> ?C 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. l6 <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: 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 then before putting the well in use. The above <br /> information is true to the best of my.knowl ge an belief. I WILT. CALL FOR A GROUT INSPECTION <br /> PRIOR TO G NG AND A FIN 0 <br /> SIGNED © TITLE l e <br /> RAW PLOT PLAN ON6MVERSE, SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE j /7 -7. <br /> ADDITIONAL COMMENTS <br /> PHASE II aOUT INSPECTICrN PHASE III/FINAL INSPECTION <br /> INSPECTION ,BY -, DATE INSPECTION BY , DATE <br /> E H 1426 Rev 1-=7'4--- 376 2M �; <br />