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SAN JOAQ UIN LOCAL HEALTH DISTRICT <br /> FOVOFFICE USE: 1601 E. Hazelton Ave. , Stockton., Calif. <br /> ' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. (aZ -.776 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 wade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Lacal Health District. <br /> '•'JOB ADDRESS/LOCATION.. 6 �v gp a�� .. CENSUS TRACT <br /> Owner's Name 17 Phone <br /> Address" [ = /f/Lyt�c� .�c� J�� City . . <br /> contractor's .Name k License # `'// 6,9z, Phone 11Z� - <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN RECONDITION /? DESTRUCTION- /-T . <br />' PUMP INSTALLATION / //�PUMPrREPAIA=/� PUMP-REPLACEMENT—f7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES / PIT PRIVY <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT�0 OTHER <br /> IN <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 /> i Domestic/private Drilled Dia. of Well. Casing <br />' Domestic/public Driven Gauge of Casing <br /> Irrigation i Gravel. Pack Depth of Grout Seal �— <br /> Cathodic Protection Rotary " ' Type of Grout <br /> i Disposal Other I Other Information ' <br /> Geophysical. i ' ,,"Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' <br /> Type 'of Pump . •. h H.P. <br /> PUMP REPLACEMENT: / / State Work- Done <br /> PUMP !REPAIR: L7 State Work Done % <br /> � 1 <br /> pESTRUCTION 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 new well., I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify ,themAbefore putting.the..welI 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 GROUTING F . INSPE CT ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> r FOR DEPARTMENT USE ONLY <br /> ` - PHASE I { <br /> -APPLICATION ACCEPTED BY ' '` " DATE i� ;� `�`71 <br /> ~'ADDITIONAL COMMENTS: /.- 7� ` <br /> i PHASE II GROUTIINSPECTION P SE II PFINAVINSPECTION <br /> INSPECTION BY 1 DATE i�/- 3. INSPECTION BY DATE 11-a '-Z-�(` <br /> i E H 1426 Rev. 1-74 �.,;., ,,:,,,Y r 1-74 2M <br />