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SAID JOAQUIN LOCAL HEALTH DISTRICT <br /> FOAL OFFICE USE: v 1601 E. Hazelton Ave. , Stockton, Calif:. <br /> Telephone: (209) 466-6781 <br /> API'1;TCATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS-PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> x.. (Complete In Triplicate) <br /> Applicationis hereby.made .tolthe 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 Sam Joaquin. <br /> County Ordinance No. 1862 and the-Rules and Regulations of the San Joaquin Local Health District. <br /> JOBZADDRESS/LOCATION 9G o G f ,. I YI✓C D_' CENSUS TRACT <br /> i -- <br /> Owner's Name �11 J _ 023 b�r Z YAIC Phone <br /> Address,- F. .. .0 City <br /> Contractor's Name. CX [jf License <br /> Phone .ya 7 <br /> i r <br /> s <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /� RECONDITION /_� DESTRUCTION /7 <br /> PUMP INSTALLATION / J ' PUMP REPAIR /� PUMP REPLACEMENT �1 T <br /> 3 Other <br /> VDISTANCE TO NEAREST: SEPTIC TANK } � J'SEWER LINES - PIT PRIVY <br /> SEWAGE DISPOSAL: FIELD CESSPOOL/SEEPAGE PIT OTHER �t <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well. Excavation ' <br /> _ Domestic/,private Drilled'-^' Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing j <br /> Irrigation ► Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal `. i Other, O.ther-Information <br /> Geophysical Surface Sean Installed By* <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 'f i! _�, ,. r H.P. . <br /> PUMP REPLACEMENT: / / State Work Done <br /> Pi .REPAIR: 1-7 State Work Done _ {, <br /> ,RES;TTRUCTION 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 'rew,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.uae.. The above <br /> information is true to the best ofmy-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOQR=iNG AND.A F NAI. TMRPPrTION. <br /> SIGNED TITLE f <br /> PLOT PLAN ON REVERSE SIDE) 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY "N ATE / '„'� Q <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHASE III ,FINALINSPECTION <br /> INSPECTION BY DATE ; . INSPECTION- BY DATE, ,� 7 <br /> E H 1426 Rev. 1-74 - ���.`.;a 1-74 2M <br />