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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OPFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2!.Z-30—) )0 <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 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 9,9 CENSUS TRACT <br /> Owner's Name Phone 11M f F,6 <br /> Address City <br /> Contractor's Name License PhoneG <br /> l <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN / / RECONDITION /% DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT 17 ' <br /> Other / / --- -- - -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY r <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, of Well Casing 1� <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 <br /> Geophysical Surface_Seal,-Installed By:__ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 0 <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: f / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all Tlaws 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 C FOR A GROUT- INSPECTION <br /> PRIOR TO GROUTING D A FINALSP ION. <br /> SIGNED TITLE <br /> DRAW PI. T PLAN ON RE EkSE SIDE) <br /> OR EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE I_2- <br /> Z-77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE.I: I/ N_AL*:YNSPE- T�. <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />