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SAN JOAQUIN LOCAL"HEALTH DISTRICT <br /> FO—ReWFICE µ E: 1601 E. Hazelton Ave. , ,Stockton,:.,Calif. : <br /> Telephone. ('-(209) 4664781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. LZZ 4 <br /> THIS PERMIT .EXPIRES 1 -YEAR,F"ROM_.DATE ',ISSUED aDate Issued -o2S-7f <br /> -" (Complete- In Triplicate) <br /> Application is hereby made to the San Joaquin.Local Health Disttict.-for a,.'permit .to const`ruct's <br /> and/or install the work herein described. This application is, made:jp' compliance with Sin Joaquin <br /> :County Ordinance No. 1862�and.-the Rules andiRegulations' of.. the.,.San>Joaquin Local Health-District'. <br /> JOB ADDRESS/LOCATION 1"o !' 'CENSUS 4RA& { <br /> Owner t s Name rri���rrrr�?a- Y Phone <br /> Address'.; - City <br /> Contractorts Name License #. 4.7AC Phone - 73 <br /> CIPf <br /> TYPE OF WORK (Check): NEW WELL,L 7 DEEPEN 'J7 RECONDITION/ 7 DESTRUCTION'/-7 <br /> i PUMP INSTALLATION /� PUMA REPAIR / FUMP REPLACEMENT . <br /> Ether <br /> I � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER'LINES ' .PIT PRIVY <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...af Well Casing <br /> 5 Domestic/public Driven Gauge of Casing <br /> Irrigation Gravei Pack I 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 i R.P. <br /> PUMP REPLACEMENT: / / State. Work Done . __ . _ _ r. .. _ <br /> PUMP-'REPAIR: wWo <br /> State rk-Done <br /> ESSTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t I hereby agree to comply with all laws and regulations of the Sart Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> i 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 CALI FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING .AND A FINAL INSPECTION. <br /> SIGNED l TITLE ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> r <br /> FOR DEPARTMENT USE ONLY , <br /> G PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ij DATE G <br /> } E H 1426 Rev. `1-74 1-74 2M <br />