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SAN JOAQUIN LOCAL HEALTFI.DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave., 'Stockton, Calif. <br /> ( Telephone.: (209) 466"=6781 <br /> ' APPLICATIONI'FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �; r <br /> i 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 Joaqui <br /> County .Ordinance No. 1862 afid the Rules and Regulations',of the San Joaquin Local Health District, <br /> j S �- <br /> JOB ADDRESS/LOCATION ,, 1 Q� �%�/c�-d�, � CENSUS TRACT' <br /> Owner's Name ✓ � lV �-�! '7�T. &!2 l �� <br /> IPhone. <br /> Address. City <br /> Contractor's Name License # Phone Fd�s <br /> {'TYPE OF WORK (Check): NEW WELL / J DEEPEN '/_/ RECONDITION /_/ DESTRUCTION <br /> AL <br /> ' PUMP INSTLATION '/ / PUMP REPAIR PUMP REPLACEMENT /T <br /> f 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 CONSTRUCTION SPECIFICATIONS <br /> TYPE OF WELL \ <br /> Industrial Cable Tool Dia.jof Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation r Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type; of Grout <br /> Disposal Other Other Information'.- <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor " <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP_REPAIR: .. State..Work Do <br /> V. <br /> DESTRUCTION OF WELL: Well Diameter 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 befor€'..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 INSPEC ON <br /> PRIOR TO OUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE ' <br /> �Aoa� <br /> (DRAW'PIs T PLAN 'ON REV <br /> EtSE SID <br /> FOR DEPARTMENT° USE ONLY - -•----- <br /> PHASE I <br /> APPLICATION ACCEPTED EY+ ii <br /> ADDITIONAL COMMENTS: DATE <br /> " PHASE II GROUT INSPECTION PHASE7 FINAL INSPECTION <br /> f' INSPECTION BY DATE INSPECTION BY DATE <br /> E _ ' <br /> ► ��E�H 1426 kev. 1-74 3/76 at <br />