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` y SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR.OFFICE USE:, 1601 E. Hazelton Ave. , ;Stockton, Calif. <br /> q/2-9 IC69* :. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 22 ZZ2h r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED q• Date IssuedaG-7� <br /> (Complete In Triplicate) <br /> Application is tereby"made tothe 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 Joaquin4 <br /> County Ordinance No. 1862 and the Rules and Regulations .of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .Z U % <br /> CENSUS TRACT <br /> Owner's Name <br /> �D � Phone ,5 a <br /> City ; <br /> Address <br /> iLicense #., ([� Phone q y 1--5. <br /> Contractor s Name Al <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other : ,/—/ <br /> DISTANCE TO -NEAREST: SEPTIC`TANK,ZS� SEWER LINES rr ` PIT PRIVY > <br /> SEWAGEjDISPOSALfFIELD �--- CESSPOOL/SEEPAGE PIT OTHER --- 1 <br /> PROPERTY LINES PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL ,� �• <br /> Industrial - _ Cable Tool Dia. 'of Well Excavation y " <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing <br /> e,4 i4er <br /> --1j�- Irrigation t Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal I Other Other Informatiion ' <br /> Geophysical Surface Seal Ins talied�_B <br /> nPM INSTALLATION: Contractor <br /> Type of Pump ' R.P. p <br /> PUMP REPLACEMENT: / / State Work Done _ - <br /> PUMP: .REPAIR: / / State Work Done <br /> ° Approkimate ,Depth' � <br /> DESTRUCTION OF WELL: Well 'Diameter <br /> to Describe Material and Procedure <br /> I .hereby agree to comply with all laws and regulations of the San Joaquin Local Hea th District <br /> andothe State of California pertaining to or regulating well"construction. W3.thi-n 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/offy them before putting the -well in.use. The above <br /> information is true to the st f mwledge and belief. I ^WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TING A FINP S~ <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON.REVERSE SIDE <br /> FOR DEPARTMENT VSE ONLY <br /> _r/O <br /> j PHASE I �R DATE G-?� <br /> ` APPLICATION ACCEPa Y 1.1 <br /> , ADDITIONAL COMMENTS: '� PHASE I /FINAL INSPECTION <br /> PHASE II GROUT' s ATE _ -7 <br /> INSPECTION. BY ... _ -;DATE . ..,.INSPECTION:BY <br />