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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 7 #6 G <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . Date Issued <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 Joaqui <br /> County Ordinance No. 1862 and the Rules andegulations ;the San -Joaquin Local Health District. <br /> i Pclvl�_� <br /> JOB, ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name ` L /1Phone�r� <br /> iz 6 <br /> Address f City <br /> � <br /> Contractor's-Name. �1?-�y� - � � � � License �� � ?Phone <br /> - � � <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / RECONDITION / / DESTRUCTION /_7 <br /> PUMP' INST L TION IYI PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> j <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE�/a2 PIT PRIVY <br /> ° SEWAGE DISPOSA� I, FIELD jtzP 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 of-Well Excavation 2_ tr <br /> ,Dome stic/private. Drilled" � Dia. of Well Casing <br /> Domestic/public v.-.1 Driven Gauge of Casing _ C <br /> Irrigation _ . Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary, Type of Grout Q <br /> Disposal `Other Ofher`,;Information <br /> Geophysical -Ins'Surface'.,Sealtalled By: <br /> Q <br /> PUMP INSTALLATION: -_ Conn aco'r <br /> Type- of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: WelltDiameter 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 anew 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. . TWILL CALF: FOR A GROUT INSPECTION <br /> PRIOR TO ROUTING AN A F CT 0 <br /> TITLE e�� <br /> i W PLOT AN ON REV RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 1 PHASE I <br /> APPLICATION ACCEPTED BY DATE-- - <br /> ADDITIONAL COMMENTS: <br /> PjiAS UPYCTION PHAS �_I/FISAL INSPECTION <br /> INSPECTION BY T W - INSPECTION BY DATE / <br /> 1 3 ,, {,fit - S� - 2M <br /> E H 1426 Rav_ . 7-7G o1 7.7 <br />