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3 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT' <br /> FOFxOFFICE USE: r 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i . Telephone: (209) 466-6781 - 11�1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT .EXPIRES l YEAR FROM DATE ISSUED Date Issued 722­7c' <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 JoaquinCounty Ordinance No. `186 andRule and Regulations o e San Joaquin Local Health District,. <br /> ' JOB ADDRESS <br /> /LOCATION x a 1 ,/ <br /> ENSUS TRACT <br /> Owner's Name If'a"G <br /> Phone <br /> Address d- <br /> Ci )) <br />} Contractor's Name License �hone`,,)'�Z � <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN -/-7 RECONDITION 1-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION/7 PUMP REPAIR PUMP REPLACEMENT /7 <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 <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'/P � Driven Gauge of Casing <br /> Irrigation Gravel Pack, Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout '{ <br /> Disposal Other - Other In€ormation ; <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . j-7 State Work Done-- <br /> LP 11 -REPAIR: ��QkState�Work Don _ \ <br /> �' 1­_ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withfall laws and regulations of. the-San Joaquin local Health District -I <br /> land the State of California pertaining to or regulating well "c'onstruction.. Within FIFTEEN DAYS <br /> :after 'completioa of my work on a new well, I will furnish the San Joaquin Local Health District a f <br /> WELL DRILLERS REPORT-of 'the well and notify them before putting..,the .well. In.use.... The above <br /> information is true to the-beit of my...knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROUTING'AND A FINAL 'INSPECTION. <br /> SIGNED 7)7 (aTITLE <br /> I' _ .4 `, DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE FI I'. t i <br /> ON' <br /> APPLICATI .:ACCEPTED° BY .DATE �/ 7 <br /> ADDITIONAL COMMENTS: i <br /> .try.j.)PHASE II OUT INSPECTION PHNhhINAL INSPECT <br /> IN5PECTIONtBY5 ,. DATE INSPECTION BY- LIIXVKWJ DATE (� <br /> T ._ <br /> E H'1426 Rev. 1-74 - �.��e �u <br />