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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FO1, OFFICE USE: 1601 E. Hazelton Ave. , Stockton,� Calif, <br /> Telephone: (209) 466-67811 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DA�E ISSUED <br /> ' 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, �1�2 nr� the Rules Regulations of tt'e San Joaquin Local Health <br /> .OA <br /> � "� � � District. <br /> JOB ADDRESS/LOCATION <br /> 4 S, ENSUS TRACT <br />;Owner's Name 4 �F myE.ns <br /> 1/ Phone <br /> Address e <br /> city <br /> Contractor's Name <br /> License 0/ Phone a '- ',gip <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN i <br /> _/ / RECONDITION � DESTRUCTION /� <br /> PUMP INSTALLATION / / _PUMP REPAIRiM PUMP REPLACEMENT /_7 <br /> Other 40 ` <br /> Vi <br /> DISTANCE TO NEAREST: SEPTIC TANK �I. "'•' <br /> SEWER LINES PIT PRIVX <br /> - - -- -- -SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> " OTHER p <br /> PROPERTY LINE - PRTVATE DOMESTIC WELL �� PUBLIC DOMESTIC WELT, ' 1 <br /> INTENDED .USE TYPE OF WELL r <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Weill Casing <br /> Domestic/public �. Driven <br /> Irrigation Gauge of Cab ing <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectionRotary Type of Grout(� ` <br /> Disposal ', Other Other,Inforiation "F <br /> Geophysical E. <br /> Surface Sdal-Installed <br /> PUMP INSTALLATION_: <br /> Contractor <br /> . Type of Pump '1 <br /> H. <br />'UMP REPLACEMENT: State Work' Done - - — <br />'UMP, REPAIR:,'K�" ,,. . ,- / <br /> / ; State Work Done ,,, , <br />'ESTRUCTION OF WELL:- Well Diameter <br /> Approximate Depth r <br /> Describe Material and Procedure NIM ------�— <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health ,District <br /> nd the State of California pertaining to or regulating well ''canstruction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting the well. in use. The above <br /> nformation is true to the best of my.°`knowledge and belief. I WILL CALL FO A GROUT INSPECTION <br /> 7IOR TO GR TI G A FINAL, INSPECTION: <br /> IGNED II <br /> ' TITLE ' <br /> . , f (DRAW PLOT PLAN ON REVERSE 'SIDE) <br /> SASE I <br /> FOR DEPARTMENT USE ONLY <br />?PLICATION ACCEPTED BY <br /> " eoot? DATE <br />)DITIONAL COMMENTS; . <br /> PHASE II GROUT INSPECTION PHASE I/F AL INSPECTION <br /> dSPECTION BY DATE INSPECTION BY. <br /> DATE <br /> r <br /> E H 1426 Rev. 1-74 <br />