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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 16D1 E. Hazelton Ave. , Stockton, Calif. <br /> I ': Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-17%O'7 <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i <br /> I Date Issued <br /> (Complete In Triplicate) —y <br /> Application is hereby made tofthe 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 A] } t L P r 4- <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address R 0 X r <br /> City �1 Cf <br /> Contractor's Name <br /> e �" (� U <br /> License # Phone r/t <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN _ <br /> _/ / RECDNDITION /_/ DESTRUCTION /_7PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT <br /> Other <br /> DISTAfiiCE TO NEAREST: SEPTIC TANK �- ' <br /> SEWER LINES _ ; T <--PIT i?tIVY f; <br /> T--S-EWAGE DESPOSAZL-FIELD-�—•-�-T-� CESSPOOL%EEEPAGETPTT`� <br /> PROPERTY 'LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC TIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br />� Orhestic/private Drilled \ <br /> Domestic Dia, of Well Casing Q <br /> /public Driven Gauge of Casing /2 tl <br /> Irzigation vel. Pack Depth of Grout Seal <br /> r <br /> Cathodal Protection - Rotary Type of Grout '� \ <br /> Disposal <br /> GeppbysGeophysicalt other r`----- <br /> Other Information <br /> Surface Seal Installed By: <br /> a <br />'UMP INSTALLATION: Contractor '--�- - -- --^^-- <br /> ' <br /> Type of Pump H.P. 1 <br />'UMP REPLACEMENT: /_7 State Work Done j <br /> UMP .REPAIR: ' / / Stale Done <br /> ES•TRUCTIQN OF WELL: Well Diameter <br /> , e ApproximatDepthDescribei 4 <br /> hereby 'agree to comply with all laws and reg`ulafions of the- San Joaquin Local Health District <br /> ad the Stdte of California pertaining ,to or regulating well construction. Within F'IFT'EEN DAYS y <br />[ter completion of my work on a new well, . I-will -fur- ish-the San Joaquin Local Health District a �! <br /> ELL DRILLERS REPORT of the well and notify them before putting the. well in luse...�i2 -above: <br /> iformataon is true to the best"' of my knowledge and belief. I WILL CALF FOR A GROUT INSPECTION <br />'10R TO GRD ING AN A FINAL INS TI <br /> CGNED . <br /> (DRAW PLOT PLAN ON REVERSE SIRE} __`" —!' i <br /> LASE I ! FOR DEPARTMENT USE ONLY- , <br />'PLICATION ACCEPTED BY ^ ' <br />)BIT1DNAL COMMENTS* ` .DATE <br /> P SE <br /> fSPECTION BGROUT INSPECTION P S I/FINAL INSPECTION <br /> Y DATE � - INSPECTION BY DATE _ �'� ' <br />.,E-H 1426 Rev. 1-74 1 . 77 <br />