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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OF <br /> FOFFICE USE: 1601 E. Hazelton ., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,� -. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedO-,7, <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 C'(,lT ' �S / ROOD CENSUS TCT <br /> Owner's Name _ eJ LA,LIA l R S A A Lx<-.��_ Phone �A�'�l <br /> Address 916 & taut-d fius-rmo R04D � City 5TO Mao <br /> Contractor's Name4 License # z -- <br /> '. <br /> Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INS ALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANKC SEWER LINES C?j�" PTT PRIVY <br /> SEWAGE DISPOSE-FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL _ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> dustrial Cable Tool Dia, of Well Excavation Ze <br /> Domestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public Driven Gauge of Casing Z. <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: 1 <br /> PUMP INSTALLATION: Contractor c,-y./° /i <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <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 FIFTVEN 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED USL a, 7 , TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY t�7. <br /> j PHASE I <br /> APPLICATION ACCEPTED BY � DATE <br /> ADDITIONAL COMMENTS:CI O stvc ileo <br /> PHASE II GROUT INSP CTION Ax — III/FIN INSPECTION e <br /> INSPECTION BY DATE PINSPECTION BY DATE <br /> E H 1426 Rev. , 1-74 <br />