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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. - <br /> Telephone: (209) 466-6781 <br /> r 1 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZL)6 N3 <br /> { <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2a_$-7x <br /> (Complete In Triplicate) <br /> _Application istiereby made tolthe 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 <br /> ddjithe Rules and Regulations of the San Joaquin Local Health District. <br /> -JOB ADDRESS/LOCATION CENSUS TRACT <br /> { Phone <br /> Owner's Name ¢ d <br /> Address A Ccs L City <br /> Contractor's Name License , _ac.7 !Phone- . 03.�d <br /> z . <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN ./ / RECONDITION / / DESTRUCTION <br /> AL /—/ —PUMP <br /> PUMP INSTALLATION / / PUMP REPAIR / /—PUMP REPLACEMENT /7 <br /> Other './ / �� _ - <br /> t m <br /> DISTANCE TO NEAREST: SEPTIC;TANK SEWER LINES -11 PIT PRIVY <br /> -/�`�CL-�"�C 00 /SEEPAGE PIT� OTHER Q' <br /> PROPERTY LINE - PRIVATE DOMESTICWELL- PUBLIC DOMESTIC WELL <br /> INTENDED USE *TYPE OF . ELL CONSTRUCTION SPECIFICATIONS <br /> I trial Cable Tool Dia. of Well Excavation_ " <br /> T omestic/private _ . . _.r D.rilled.�. <br /> Dia. of Well Casing`,, ` <br /> Domestic/public Driven Gauge-of Casing <br /> Gr--ave! PacR Depth of Grout Seal <br /> Irrigation � <br /> Cathodic Protec't3-on, _ Rotary Type of zz <br /> Grout f <br /> Disposal v , ��! Other Other InfOrmati0n1 <br /> Geophysical' 1 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Typelof Pump 7 ^� <br /> PUMP REPLACEMENT:' / / 'State Work Done <br /> PUMP .REPAIR: 1 / / State Work Done <br /> i DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I <br /> �i 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 DA�,S <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 true to the/�est of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRANG D A F WAL VSPECIION. A + <br /> SIGNED TITLE C'l <br /> r (DRAW OT PLAN ON REVERSE SIDE <br /> F R DEPARTMENT USE ONLY -7 <br /> PHASE I DATE <br /> . APPLICATION ACCEPTED BY Q <br /> ' e ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III AL INSPECTION — <br /> F INSPECTION BY DATE INSPECTION BY q DAT / L <br /> ` 1177 2M <br /> c u 3419 n.... 1_74 <br />