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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�.QFFICE USE; OY1601 E. Hazelton'Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. LLs� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ZZ- <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local health Distract far 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 �,� G LIDt 5c7ir_1 , CENSUS TRACT <br /> Owner's Name -� <br /> »✓ Phone 3 9' c;2.3'-1 <br /> Address S'a z5 <br /> City . . ©f� <br /> Contractor's Name /�� / -r , License #.2P �� <br /> 0% hone <br /> TYPE OF WORK (Check): NEW WELL:`/-7 DEEPEN /_7 RECONDITION 17 DESTRUCTION /7 <br /> PUMP INSTALLATION -/—/ PUMP REPAIR/? PUMP REPLACEMENT <br /> Other' / / <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 \ i <br /> INTENDEDUSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS {� <br /> Industrial Cable Tool Dia. of Well`Excavation l � <br /> Domestic/private ~ Drilled Dia. of Wel.l.Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel -Pack Depth-of Grout-Seal '- <br /> Cathodic:Protection w Rotary Type of Grout <br /> Disposal Other Other Information t <br /> Geophysical Surface Seal Installed "By:' <br /> I <br /> x <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump , <br /> H.P. <br /> PUMP REPLACEMENT: State Work Done frry'dy <br /> PUMP !REPAIR: / / State work Done <br /> 1 <br /> DESTRUCTION OF WELL: Well Diameter f <br /> 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. ift.use.... The above <br /> information is true to the-best -of- my knowledge and belief. -I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG UTING D A FINAL INSPECTION. <br /> SIGNER <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SID i <br /> l FOR DEPARTMENT USE ONLY <br /> PHASE 1, f r ' <br /> APPLICATION' ACCEPTED BY�3 <br /> ADDITIONAL COMMENTS: DATE .. /7_( <br /> PHASE -11 ' ROUT INSPECTION PHAW III INAL INS <br /> PECTTDN <br /> INSPECTION BY DATE INSPECTION BY DATEZ72 <br /> E H 1426 <br />