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C SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F05;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2L-A.U4,) <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 76 <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 Joaqui <br /> County'Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ��/�'W��p .00 S EG, .2G IT k 7- 1 u CENSUS TRACT <br /> Owner's Name Phone <br /> Address 2, 1 City ` <br /> Contractor's Name �l.(f License # Phone <br /> TYPE OF WORK (Check): NEW WELL - DEEPEN '/? RECONDITION ff DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR-/ PUMP REPLACEMENT /? <br /> / <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 Q <br /> j INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial , X Cable Tool Dia. of Well Excavation ,� Z <br /> 'Domestic/privateI Drilled Dia, of Well Casing / ,2 <br /> Domestic/public i Driven Gauge of Casing / y <br /> Irrigation '. 4 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ' <br /> I' Disposal' i Other Other Information <br /> Geophysical- I Surface Seal Installed 'By' <br /> PUtT INSTALLATION: Contractor <br /> -Typerof Pump "H.P. <br /> 1PUMP REPLACEMENT: /_7 .State Work Done y <br /> 1 PUMP ,REPAIR: <br /> Ll Work Done <br /> P&TRUCTION OF WELL: .Well Diameter Approximate Depth <br /> Describe Material and Procedure. " <br /> 11 hereby agree to comply with all laws and regulations of the Sin-Jonquin 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well in.use...: :The-above <br /> linformation is true to the•best•of myknowledge and belief. I WILL CALL 'FOR A GROUT INSPECTION <br /> PRIOR TO GR TING AN FINAL INSPECTION. <br /> SIGNED ti TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I y T <br /> APPLICATION ACCEPTED BY ,Q�/ DATE 76� <br /> (ADDITIONAL COMMENTS: <br /> PHASE If GROUT INSPECTION' PRASE III FINAL INSPECTION <br /> INSPECTION BY DATEINSPECTION BY DATE ,4 - -� <br /> F <br /> 11 1L9A Dn.� 1..74 - — 4/75 al <br />