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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFx:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> Zl3_=.5::.�c.4 ;�"2 - (Complete In Triplicate) ZS3-i 0 --1 Z <br /> Application is hereby made' tn 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 . ] 'L CENSUS TRACT <br /> Owner's Name .-L� Phone <br /> Address -- w � City <br /> Contractor's Name License #1613 7.3 Phone.34 <br /> TYPE OF WORK (Check) : NEW WELL '/—/ DEEPEN ../—// RECONDITION /_7 DESTRUCTION /_7 'D <br /> E PUMP /INSTALLATION / PUMP REPAIR PUMP REPLACEMENT /? W <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �l <br /> SEWAGE DISPOSAL FIELD 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 Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 4 <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 <br /> Type .of Pump <br /> PUMP REPLACEMENT /7 State Work Done '- <br /> PUMP .REPAIR: - - _ State Work Done :&a <br /> DES-TRUCTION OF .WELL:-'x°- Well 'Diameter �-- -. , - - Approximate Depth <br /> Describe Material and Procedure <br /> t <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 GWIN22 AND AL INSLECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY MY DATE 2-13-76 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PW <br /> SE TIIftINAL INSPECTIOtf <br /> INSPECTION BY _ DATE INSPECTION BY DATE 12 <br /> 1./*7 Cf Olaf <br />