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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 .. NX <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �.�7p 1 <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 fora permit to construct <br /> and/or install the work herein described. This application is made .in .compliance with San Joaquin <br /> County Ordinance bio. "186"2 aind the Rules and Regulations of the Sass Joaquin Local, Health 'District. <br /> JOB ADDRESS/LOCATION _4Co L7I ;� 4 . � Q. CENSUS TRACT " ' <br /> Owner's Name L <br /> ��Phone" <br /> Address s-n :4 <br /> city P+ ,[o,J <br /> Contractor's Name License !2�e Phone <br /> TYPE OF^WORK -(Check)s NEW,WgLL;:/7A DEEPEN /iT ,.RECONDITION / � DESTRUCTION /_7 <br /> PUMP INSTALLATION/_/ PUMPREPAIR' vFUMPyREPLACEMENT. f]" <br /> N Other i/ / <br /> DISTANCE TO NEAREST: ` SEPTIC TANK SEWER LINES PIT.PRIVY— <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 1PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC-DOMESTIC WELL : <br /> INTENDED USE . TYPE OF WELL CONSTRUCTION SPECIFICATIONS,_.,,,,_._ \� <br /> Industrial .",-" r- Cabl'e`Tool­ "Dia, of Well Excavation <br />' . Domestic/private Drilled- Dia. of Well Casing <br /> Domestic/public: Driven Gauge of Casing <br /> Irrigation ° Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary' -Type of Grout " <br /> Disposal Other -Other Information �- <br /> Geophysical Surface Seal Installed 'B : <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump ; H.P. <br /> PUMP REPLACEMENT: / / State Work Done . Jt <br /> F PUMP REPAIR: ' , St , <br /> ate Done: r 42 <br /> � . . <br />` DESTRUCTION OF WELL:4 Well -Diameter 6 ,; Approximate Depth <br /> ! Describe Material and Procedure <br />, .I hereby agree to comply with. all laws -and regulat'ions of the San Joaquin Local Health District <br /> And the State of California pertaining to or regulating well''construction. Within FIFTEEN DAYS <br /> t -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 GROUT INSPECTION <br /> PRIOR TO GRO ING 'AND A INAL INSPECTION. <br /> SIGNED4C TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i <br /> APPLICATION' ACCEPTED BY DAT$ <br /> ADDITIONAL COMMENTS: <br /> E PHASE II GROUT-INSPECTION' WIII <br /> PHA INAL INSPECTIO <br /> INSPECTION BY. DATE INSPECTION BY DATE <br /> dv <br /> E H'1426 Rev. 1-74 L17q' 2M <br />