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°` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : - _-Z209)0.466-6781 G <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �d <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 Regulation of the San Joaquin Local Health Distrigt. <br /> J09 ADDRESS/LOCATION Q'3Q1 5' CENSUS TRACT <br /> - y <br /> Owner's Name -- __ .^,._._0 _ _.._ 3� Phone _:?6X-..36146 <br /> 19~0 _ /91►14�' 0 q° <br /> _..- _ <br /> Address Wopo X7,Q.�/ L,Q City "49/ <br /> Contractor's Name License # one <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INS LATION / / .PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK --SEWER LINES PIT PRIVY --�' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT -`OTHER r <br /> PROPERTY LINE @PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS CM <br /> Industrial �_ Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing /Z 't- <br /> Irrigation Grave]. Pack Depth of Grout Seal --.- <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information _ <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> _ E <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION 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 /> WELL DRILLERS REPORT of the well 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 GROU ING AND A FINAL I.NPUTION. <br /> SIGNED TITLE �v _�j <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - -- <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECT N <br /> INSPECTION BY DATE INSPECTION BY -,__ DATE 23 <br /> E H 1426 Rev. , 1-74 <br /> 0�77 2M <br />