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f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT j <br /> FGF� OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. + <br /> Tele.phbne: (209) 466--6781 r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/ ` '7 <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 K F CENSUS TRACT <br /> Owner's Name L, [ E? (j `. Phone <br /> - <br /> Address -?40130y,. 134 A/TS ! -C4& City <br /> Contractor's Name C1 - ( License # 'hone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION /7 DESTRUCTION /_7 �J <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / � <br /> ' N� .� <br /> DISTANCE TO NEAREST: SEPTIC TANK &2SEWER LINES r PIT PRIVY <br /> SEWAGE DISPOSAL j,1ELD = CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINED` RIVATE .DOMESTIC 14ELL = PUBLIC DOMESTIC WELL - <br /> INTENDED USE TYPE OF WELL # + CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled i Dia. of Well Casing. <br /> Domest'c/public Driven Gauge of Casing J4 <br /> Irrigation Gravel Pack ( Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other -. Other Information <br /> Geophysical `r Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor — <br /> � ' <br /> Type of Pump, '.,r H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done ;8 <br /> DESTRUCTION [OF WELL: Well Diameter r _ Approximate Depth <br /> T Describe Material. and Procedure--- <br /> I <br /> rocedure--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 GROUTMG AND FINAL P CT ION. TITLE _ JrefJ <br /> SIGNED — <br /> DRALd PLOT PLANT ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I { <br /> APPLICATION ACCEPTED BY r ry <br /> , , DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION HASF <br /> JIVFINAL IN ECTION <br /> INSPECTION BY DATE INSPECTION BY E <br /> n;j 7 7 2M <br />