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f lld ��cow./ 04 �+ �� �� SAN JOAQUIN LOCAL` HEALTH DISTRICT <br /> FOB OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 456-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7L/`a y/P <br /> THIS PERMIT EXPIRES 1 YEAR FROM-`DATE''LISSVED Date Issued 6-/3 <br /> .1* (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 Joaquini <br /> County Ordinance No. 1862 and the-Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S On ES- a d �vr' S+ �►-�- CENSUS TRACT 1k3--g)(0a2 <br /> Owner's Name C&[- Phone <br /> Address `� �� ,�,r�. <br /> ��r �� City <br /> Contractor's Name `' License # 7��Phone <br /> ff <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN /? RECONDITION /7 DESTRUCTION /7.. <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /? <br /> Other <br /> 4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br />'f �. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT - OTHER <br /> G PROPERTY LINE " PRIVATE DOMESTIC WELL .. PUBLIC DOMESTIC WELL � . <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> s Industrial Cable Tool - Dia. of Well Excavation -' <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> G Irrigation Gravel Pack Depth of Grout Seal _= <br /> Cathodic Protection Rotary Type of Grout' <br /> ` -Disposal Other Other Information r <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION% Contractor <br /> Type of"Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ',REPAIR.: JXJ t State Work Done <br /> ESES•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 6f, California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> i 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 puttin:g.the .well in use. The above <br /> information is true to the-best y.knowl and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO 2AgTING AND A FINAL INS13ECDWN. <br /> SIGNED TITLE e'G.. <br /> ` RAW PLOT PLAN ON RMERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> - f <br /> APPLICATION ACCEPTEDY DATE <br /> ADDITIONAL' COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �- <br />' .� E H 1426 Rev. 1-74 1-74 2M _�..3 <br />