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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: Ll-� 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' i 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 made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> o F 1jLL 4 \,V/S �- CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> e�41 F SrEt_ Phone1 <br /> Owner's .Name �taf�I Pf <br /> Ha 6A nr - City �-- <br /> Address jS <br /> Contractor's Name ®. � _ <br /> License # �JPPhone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL I I DEEPEN '/ / RECONDITION_/ / DESTRUCTION /-7 <br /> PUMP INSTALLATION /, C PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other [-7 <br /> I — N <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES- PIT PRIVY N <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 R Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia.of We11 Casing <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 ' 1 <br /> r Geophysical Surface Seal" Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. ° <br /> PUMP. REPLACEMENT: / / State Work Done .�. <br /> PUMP .REPAIR:. ;,: ` / /�--State.�Work Done <br /> t <br /> DESTRUCTION 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 thewell 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.:IN CT-ON <br /> PRIOR TO OUTING ANR A INAL INSPECTION. I <br /> SIGNED TITLE <br /> D W PLOT PLAN 4N REVERSE SIDE <br /> TMENT E ONLY <br /> PHASE I _ 6 -'� <br /> APPLICATION. ACCEPT BY L/�� T DATE <br /> ADDITIONAL COMMENTS: ECT1OuNPHASE II GROUT INSPECTIONPP 42j' FI Al.AL INS <br /> INSPECTION BY DATE INSPECTION d DATE <br /> i 3/76 2M <br /> r E H 1426 Rev. 1-74 <br />