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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO *OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. =S z7z,)-o <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 andithe Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION � � � CENSUS TRACT . <br /> Owner's Name (_ydjz)a Phone <br /> Address _ So��r ► __ City (-o ! c� <br /> Contractor's Name L)l ej / r, License # Phone:��/ <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/_7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /:� PUMP REPAIR/-7 PUMP REPLACEME9T 17 <br /> Other / / i <br /> I <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 j. Cable Tool Dia. of Well Excavation <br /> Domestic/private 11 Drilled Dia. of Well Casing <br /> Domestic/public h Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ► Rotary Type of Grout <br /> Disposal !i Other Other Information " <br /> Geophysical i ; Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _Z /"J v H.P. <br /> Type Of Pump <br /> PUMP REPLACEMENT: / State Work Done + <br /> i PUMP '.REPAIR: / / State Work Done <br />� DES•TRUCTION OF WELL: Well Diameter a —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 /> 4 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 MD A Pj.$AL INSPECTION. I <br /> f SIGNED u, r TITLE < c1 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> . PHASE I ! <br /> APPLICATION' ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II eOUT INSPECTION PHASE I I INAL INSPECTION <br /> iINSPECTION BY DATE INSPECTION BY DATE tS� <br /> 7 R 1G9F, . 12nxr- 7..74 f _� <br /> 2M=� <br />