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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0TZFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4664781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7J'--,7e84J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �,3~ <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 Regulations of the San )Joaquin' Local Health District. <br /> JOB ADDRESS/LOCATION V. . �.,/ 1Y,S, -CEN S TRACT <br /> Owner's Name t 1a� C Phone <br /> Address a0y,2. j City . v <br /> i <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN -/`7 RECONDITION /=77 DESTRUCTION /-7 <br /> PUMP INSTALLATION /7 PUMP REPAIR /-7-pump REPLACEMENT l7 L� <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY (`n <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL [' <br /> INTENDED USE N TYPE OF WELL CONSTRUCTION SPECIFICATIONS t <br /> Industrial Cable Tool Dia, of Well Excavation m <br /> Domestic/private DrilledDia. 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 By: <br /> PUMP INSTALLATION: Contractor --r9 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /% State Work Done <br /> PUMP 'REPAIR: /-7 State Work Done _ <br />' <br /> ES•TRUCTION OF WELL: Well Diameter�.o_ ,,.,..., / Approximate De th <br /> Describe Material and Procedure _/ <br /> I hereby agree to comply wit4i all Uws 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 <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 INSP CTION <br /> PRIOR TO GR UTIN AN FINAL INSPECTION. <br /> SIGNED n.c J TITLE <br /> LOT PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G T SVEQnDN PHASE I] f INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 'i E H 1426 Rev. 1-74 1-74 2M <br />