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SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> FO&rOFFICE USE: ]601 E. Hazelton. Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �[ - s6 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /._9-7¢ <br /> (Complete In Triplicate) <br /> Application is hereby made toithe 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 andthe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION, laj%o5l e CENSUS TRACT <br /> Owner's Name APCENtZ.12._ I'AA Z/ 1��. - Phone 24_: g' 7 4 6,0 <br /> Address i 0 city aW-4 7 <br /> Contractor's Name ��' License P 5-7 Phone S j� <br /> TYPE OF WORK (Check): NEW WELL/ZT-'DEEPEN '/-7 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION /`r'PUMP REPAIR /—/—PUMP REPLACEMENT f7 <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 <br /> bmestic/private Drilled Dia. of Well Casing <br /> l� dI <br /> Domestic/public Driven Gauge of Casing f <br /> Irrigation 1 Gravel Pack Depth of Grout Seal s� <br /> Cathodic Protection I Rotary Type of Grout1 <br /> Disposal ' Other Other Information <br /> Geophysical Surface Seal Installed By: , y <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. /-A <br /> PUMP REPLACEMENT: %/ State Work Done <br /> PUMP ,REPAIR: / / State Work Done <br /> J?ES RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure i <br /> I hereby agree to comply with all laws and regulations oftheSan 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 we11 and notify them before putting the well in use. The above <br /> information is true-to the-best of my.knowledge and belief,.' I WILL CALL FOR A •GROUT INSPECTION <br /> PRIOR TO GR TI AND A FINAL IN ION. ro I <br /> SIGNED TITLE <br /> (DRAW-PLOT PLAN ON REVERSE SIDE) _ <br /> FOR DEPARTMENT USE ONLY ' s <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE '7 <br /> ADDITIONAL COMMENTS: tet. <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPECTION ` <br /> INSPECTION BY ~ DATE INSPECTION BY DATE / <br /> % <br /> 1 _YE H 1426 Rev. 1-74 1-74 2M '� <br />