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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOROFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> AP ILICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -�24 r <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Realth 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 the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION. 'lea 0c (yr CENSUS TRACT <br /> G y� h <br /> Owner's Name %- � a Phone 73 <br /> / <br /> Address .� aCity <br /> Contractor's Name '' �� : License Phone Lam- o ` <br /> TYPE OF WORK (Check) : NEW WELL L�T DEEPEN -/_7 RECONDITION /? DESTRUCTION /7' <br /> PUMP INSTALLATION f / PUMP REPAIR f / PUMP REPLACEMENT <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ly PIT PRIVY t <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 /0 <br /> 7 Domestic/private Drilled Dia. of Well Casing 4�# <br /> Domestic/public Driven Gauge of Casing f� { <br /> Irrigation., Gravel Pack Depth of Grout Seal <br /> i <br /> Cathodic Protection Rotary Type of Grout CfiJ�z-(�v <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B y [ ,: �:•�~ ,j <br /> PUMP INSTALLATION: . ,Contractor <br /> Type of Pump H.P. ; x1 <br /> PUMP REPLACEMENT: J f State Work. Done <br /> PUMP ',REPAIR: J / State Work Done <br /> ,PSTRUCTION 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 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 INSI' QN <br /> PRIOR TO GROUTING AND A FINAL jNSPECTION. <br /> SIGNED `'s, �,^ ;`f r� .,�,! TITLE <br /> �l (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEP'TEPf B DATE <br /> ADDIT ONAL CO <br /> QUT NSPECT N PHASE III/FINAL INSPECTION <br /> INSPECT DATE INSPECTION BY DATE--?-- <br /> 7/ <br /> �1 ^E H 1426 Rev. 1-74 1-.74 2M <br />