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Y SAN JOAQUIN-LOCA HEALTH DISTRICT <br /> FOR,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7i5= �iJ <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued -Zr , <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_.Re ulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION - `CENSUS TRACT <br /> Owner's Name �,� - Phone SA?_ <br /> t r <br /> Address 11=6 City A.�,, _ <br /> Contractor's Name License # /j 0 A/Phone <br /> TYPE OF.WORK. (Check)-::.• NEW,WELL•M. DEEPEN-a/Z'-RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other L-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD �jq) 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 �r o <br /> Domestic/public Driven Gauge of Casing ja . j <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;B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: <br /> j_/ . State Woxk.Ilone ; <br /> PUMP REPAIR: /_7 :tate Work-r-Donea <br />�j?ESTRUCTION OF WELL—.- Wil-1. Diameter '"` ' - Approxitmare Depth <br /> Describe Material and Procedure , <br /> I hereby agree 't6' 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 workfon_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 aborie <br /> information is true to the-best-of, my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION:'°," ,>. <br /> SIGNED ) ; -: TITLE <br /> *� ---�- - (DRAW PLOT PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> �2 <br /> a <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI PRASEn[414f <br /> &NA INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE G -_�)J <br /> ! E H 1426 Rev, 1-74 1-74 2M <br />