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ler SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7_r-_ .2 3i52� <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 7,5'7 !',ZQ N CENSUS TRACT <br /> Owner's Name 2' Phone <br /> Address `Y lJ �� � ��2 - City —' a cef!�L <br /> Contractor's Name 1�. ._;, f G�/_ LFC� Z)11-? C�L License # Phone <br /> TYPE OF WORK (Check): NEW WELL /V DEEPEN/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /r7 PUMP REPLACEMENT /7 <br /> t F ocher /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAf—FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 10 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial, Cable Tool Dia. of Well Excavation �0 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> f <br /> Irrigation Gravel Pack Depth of Grout Seal -42 <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. <br /> PUMP REPLACEMENT: /% State Work Done <br /> PUMP .REPAIR: L7 State Work Done <br /> ES,TRUCTION 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 the well and notify them before-putting the -well in use. The above <br /> information is true to the-beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIORUTING FINAL INSPECTION. _ <br /> SIGNEDTD ROTITLE �. <br /> W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I * � <br /> ,APPLICATION ACCEPTED BY (I 4 DATE <br /> ADDITIONAL COMMENTS: <br /> PRASE II ROU INSPECTIO PHAS I #SPECT 0 <br /> INSPECTION BY DATE INSPECTION B DATE <br /> w <br /> E H 1426 Rev. 1-74 1-74 2M <br />