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Y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> + Telephone: (209) 466-6781 �'4_-3X7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;Zr. - {� <br /> G THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date -Issued 3-7 <br /> ' (Complete In Triplicate) <br /> ' Application is hereby made to the Sara 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 Joaquii <br /> County Ordinance No. 1862 and the Rules and gulations of the San quiocal H al Distr t. <br /> :JOB ADDRESS/LO <br /> N/ posf /! S <br /> �v1—_ T <br /> Owner's Name1 Phone <br /> k :Address City 4!5� <br /> f Contractor's Name alicense C&OPhone ---Z--�q� <br /> TYPE OF WORK (Check.) : NEW WELL /7f--'DEEPEN -/-j JUCONDITION /-7 DESTRUCTION /"7 <br /> PUMP INSTALLATION /CREPAIR /7 PUMP REPLACEMENT %7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK �-2SEWE LINES —�'IT_ PRIVY_ <br /> SEWAGE DISP AL FIELD Q ESSPOOL/SEEPAG. P_ T OTHER ------� <br /> PROPERTY LINE -- PRIVA DOMESTIC WELL�� PUB . DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> In trial Cable To'al Dia. of Well 'Excavation' <br /> omestic/private Drilled Dia. of Well Casing`�'' [d <br /> I Domestic/public Driven Gauge of Casing-� /,.'��': , 4 <br /> IrrigationGra 1 Pack Depth of Grout Se <br /> I Cathodic Protection.- ._ otary , .- Type of Grout' <br /> _Disposal Other Other Information 6 FPS <br /> _Geophysical �Su aceeat Ins ed B ` <br /> [LUMP INSTALLATION: Contractor . Q ' <br /> Type of P Y H.P. <br /> PUMP REPLACEMENT: / / state Work Done <br /> PUMP''.REPAIR: <br /> /7 'State Work `Done. - . <br /> pES•TRUCTION OF WELL-: <br /> —� Well Diameter Approximate,Depth <br /> Describe Material and Procedure _ ' ` <br /> f <br /> I`hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Califor--nia 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 /> i WELL DRILLERS REPORT of the well and notify them before putting the..well .in.use.. The-above <br /> info on is true to the best o knowledge and belief. I WILL'CALL•FOR ,A-GROUT INSPECTION <br /> PRIOR TQ,040UTING AND <br /> SIGNED i•TITI�E t C <br /> W PLOT� PLAN ON REVERSE SIDE / <br /> FOR DEPARTMENT USE ONLY <br /> SEI _ <br /> APPLI 'Tiff CCEPTED BY C.� � 4 DATE zgs—/7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS IIII]KNATe INSPECTIO <br /> s' INSPECTION BY DATE INSPECTION BY DATE <br /> ' I F woo 4P <br /> o '�r�c� �aJiHd <br /> ' E H k426 . Rev.-I-=74 °� 1` �' " 1-74 2M <br />