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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 77 5571'1/0 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�7- 3 � <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 �'l C _ /3 L, s 7IAI PD CENSUS TRACT <br /> Owner's Name /` `N`/7 y tiVE/E!,'Sf/.��"a'tIr' t_.ST�17� Phone <br /> V, Br NI< Qi' S?dc7ehl <br /> Address F? Lf, r�47X W L° City 'S is 6A,r 9s <br /> 'Contractor's Name License # 4;Z Phone 5/ <br /> TYPE OF WORK (Check): NEW WELL/ VDEEPEN '/7 RECONDITION DESTRUCTIONf7 <br /> PUMP INSTALLATION L� PUMP REPAIR /-7 PUMP REPLACEMENT 17 <br /> Other f-1 <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 <br /> Industrial Cable Tool Dia. of Well Excavation p <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 /> Geophysical Surface Seal Installed BY: <br /> PUM INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j//- State Work Done <br /> PUMP :REPAIR: L? State Work Done <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 /> 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTI FI AL INSPECTION. <br /> SIGNED TITLE � [ <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR ARTMENT USE ONLY <br /> PHASE I �' ` <br /> APPLICATION ACCEPTED B (:� ^� . (. ' �ca� '� DATE <br /> ADDITIONAL COMMENTS: c ; <br /> PHASE II GROUT INSPECTION PHASE IiI FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE .� <br /> t WE H 1426 Rev. 1-74 <br /> 1-74 2M <br />