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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rFORiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 76 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�C _ /3 G <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4-3- ZC <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/LOCA Od j�___ CENSUS TRACT <br /> Owner's Name — Q Phone <br /> Address �' ,�p city 4/-; <br /> Contractor's Name 4 j License p/a3 Phone Y _63[?'q <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN- .'�/ RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION / PUMP REPAIR /-7 PUMP REPLACEMENT /_7 <br /> Other / / -- <br /> DISTANCE TO NEAREST: SEPTIC TANQ EWER �,I,1ES -�--�IT PRIVY <br /> SEWAGE DISPOSAL FIELD �Q -f- CESSPOOL/SEEPAGE PI a,- __ OTHER <br /> PROPERTY LINE -- P DOMESTIC WELL PUBLIC DOMESTIC WELL \ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> In strial Cable Tool Dia. of Well Excavation 44 77- <br /> omestic/private Drilled Dia. of Well Casing <br /> --_ Domestic/public Driven Gauge of Casing -- ---- <br /> Irrigation Gravel Pack Depth of Grout S <br /> Cathodic Protection teary Type of Grout r <br /> —Disposal Other _ OtherInformation <br /> � <br /> Geophysical ce Sea Installed B <br /> , <br /> } r <br /> PUMP INSTALLATION.. Contractor R <br /> Type of Pu H.P. <br /> PUMP REPLACEMENT: �I <br /> / / State Work Done <br /> PUMP :REPAIR: /? State Work Done -_LL <br /> ES•TRUCTION 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 /> W L DRILLERS REPORT of the well and notify them before puttingthe- well in use.. The above <br /> in r ion is true toa knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR OUTING AND A FIN S CTIXw <br /> SIGN TITL <br /> . <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> P <br /> FOR DEPARTMENT USE ONLY <br /> I ,/ - <br /> APPLIC CCEPTED BY U DATE 3 <br /> ADDITIONAL COMMENTS: <br /> P I 0 INSPECTI PH103-II)WFINAL INSPECTIO <br /> INSPECTION DATE INSPECTION B DATE <br /> ~E H 1426 Rev. 1-74 <br /> 1-74 2M <br />