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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E ro-E7OFFICE USE: V116101 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) ,466-6781 �G `� <br /> az <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No f <br /> i <br /> THIS' PERMIT EXPIRES l YEAR FROM DATE ISSUED Date IssuedIC <br /> (Complete In Triplicate). . <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 Sart Joaquin, Local Health District. <br /> JOB'ADDRESS/LOCATION Q,8G�/ CENSUS TRACT <br /> Phone / 8 2 6 <br /> ' Owner's Name. <br /> t . <br /> Address 0 9 rl Z_ , k"'I City ' <br /> , Contractor s Name <br /> G 00 License # Phone �6 <br /> 4 <br /> TYPE OF WORK�(Check) : NEW WE- LLY''/.7� DEEPEN - <br /> %T RECONDITION % 7 DESTRUCTION /� <br /> PUMP INSTALLATION PUMP\REPAIR-/7 PUMP REPLACEMENT /? <br /> Othet _ <br /> DISTANCE TO.NEAREST: =,SEPTIC. TANK- r ,`X - SEWER_LINES.- _ ___'_PIT PRIVY i <br /> SEWAGE~I)ISPOSAL. FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' ► PItOFERTY LINE - PRIVATE'bOMESTTC L-' PUBLIC DOMESTIC WELL <br /> INTENDED-'USE TYPE OF. WELL `s /,CONSTRUCTION SPECIFICATIONS <br /> Indus trial'�J` Cable Tcol Dia': ofr We11'Excavation <br /> t 'Domestic/private ; � '-'. -Dr --� Dia. of Well Casing <br /> - r -~ -. <br /> Domestic/public~ 3�r`, Driven k Gauge of Casing r _ <br /> 1 ^ '�;L .3'x.:3 ."� � }� 4^"ti <br /> ,Irri ation Gravel.Pack Depth of Graut: Seal =. <br /> Cathodic; Protection Rotar-y -,Type of Grout � <br /> ,Disp osa] �. .Other . � Other Information <br /> Geophysical - - ' 411_7- urface Seal Ifistalled 'By. <br /> PUMP 'INSTALLAT ON: Contractor H.P. <br /> .1 .---.7—Type of-Pump _ 494 2": <br /> PUMP REPLACEMENT. /, /' State Work Done <br /> PUMP ,REPAIR: / /% ,State Work Done <br /> DESTRUCTION OF WELL: Well Diameter i Approximate Depth <br /> - <br /> Describe Material and Procedure__._-__ <br /> I hereby agree to comply with all laws and regulations of the San J aquiri I:ocal 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 11ealth District <br /> WELL DRILLERS REPORT of the well and notify them before putting.:the .well. in-use.€W,The above <br /> information is true tot °best -of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG .AND NAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDgE <br /> FOR DEPARTMENT USE .ONLY . <br /> PHASE I. '. .#,�; . . <br /> APPLICATION ACCEPTED BY I _ DATE <br /> ADDITIONAL COMMENTS: : <br /> PHASE II GROUT .INSPECTION �` -' -J�"" ', ��PHASE III FINAL,.INSPECTION <br /> INSPCTI�N^BY - , <br /> INSPECTION BY DATE 'tom- �` ATE1/- '' - <br /> e R R 142A Rov- 1-74 <br />