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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - OHO <br /> / THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,6ft=,z -7d, <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 Regulationsf of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . � ( CENSUS TRACT <br /> Owner's Name Phone <br /> Address 4 <br /> ' ted r City <br /> J License -6A144& Phone B-2�J4 <br /> Contractor's Name <br /> i <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN '/ / RECONDITION /-7 DESTRUCTION /* <br /> PUMP INSTALLATION=.// PUMP -REPAIR" PUMP REPLACEMENT /-7 -. <br /> Other /-7 . . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 Q <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> r ; <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> a <br /> P <br /> Geophysical Surface Seal Inst, ed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> I <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Don T I 4�� <br /> DES-TRUCTION OF WELL: Well Diameter PApproximate 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 best of my. knowledge and belief. I WILL C FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING h9A FINAL IN PECTION. <br /> t SIGNED TITLE <br /> (DRA .P T' PLAN 'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> — a _ <br /> PHASE I y DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> 3/76' 2M <br /> V u 1L7F ID— 7-7L <br />