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" SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1F0k OFFME USE q' 1601 E. Hazelton Ave. , Stockton, Calif. _ <br /> Telephone: (209) 466-6781. r� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ffL-,7 <br /> x ' <br /> i 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 — CENSUS TRACT <br /> Owner's Name b ff Phone 94627- W46 <br /> Address <br /> 9z / f. [ � r / � . City _ <br /> �� <br /> Contractor's Name AIj Licensed f3Phone � <br /> t TYPE OF WORK (Check) : NEW WELL /DEEPEN / / RECONDITION /�/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR. / / PUMP REPLACEMENT /-7 <br /> Other ``cc <br /> DISTANCE TO NEAREST: SEPTIC TANK % SEWER LINES PIT PRIVY �J <br /> SEWAGE DISPOSAL FIELD _k30 1 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 <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 /> 4 Geophysical Surface Seal. Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump E.P.— <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR:.. / / State Work Done <br /> 4 <br /> DESTRUCTION 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 /> WELI. 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO G uT1NQ,7AN;D INAL INPECTTQN. ' <br /> SIGNED t <br /> W . `F TITLE _�1!!�' l e <br /> (DRAW PLOT PLAN ON RE SE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,' <br /> APPLICATION.;KCCEPTED BY DATE <br /> ADDITIONAL COMMENTS:- ;;',w:( <br /> V,GRO�T INSPECTION PHASE YII FINAL INSPECTION <br /> INSPECTION BY DATE ��� INSPECTION BY DATE <br /> 6/77 2M <br /> E H 1426 Rev. - I-74 <br />