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t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR:OFFICE USE: 1601 E, Hazelton .Ave., Stockton, Calif. <br /> { Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. &- .'2s��.J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED Date Issued S 7� - <br /> EI' (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 and the Rules and Regulations of the San Joaquin Local Health. .District. <br /> j F ; �r P f JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name r Phone ' <br /> Address _ y <br /> ._,. -&Kie <br /> f <br /> Contractor's Name ► �-° "'" . ..cense ?tisy phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN RECONDITION f DESTRUCTION <br />! PUMP INSTALLATION -j // PUMP REPAIR - <br /> . Other �/7 /? t,PUMP REPLACEMENT <br /> t— <br /> 'DISTANCE TO NEAREST: SEPTIC TANK Ot SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER' <br /> I PROPERTY LINE/0PRIVATE DOMESTIC WELT,'' ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL •`CONSTRUCTION SPECIFICATIONS <br /> Industrial a Cable Tool Dia. of Well Excavation It <br /> Domestic/private t Drilled Dia. of Well Casing t <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation. a Gravel' Pack Depth of Grout Seal <br /> Cathodic Protection ►j� Rotary Grout-'- <br /> '4 <br /> Type of Grout,', <br /> Disposal i Other F Other Information <br /> Geophysical .� . Surface Seal Installed By: <br />+ PUMP INSTALLATION: Contractor <br /> Type .of Pump S.P. <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PUMP .REPAIR: /? State Work Done <br /> DESTRUCTION OF WELL: Well.-Diameter <br /> Approximate Depth; , <br /> Describe Material and Procedure <br /> I hereby agree to comply with all lawns 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 wiIf furinish the .San Joaquin Local Health District. a <br /> WELL-DRILLERS REPORT of the well and notify them before putting the—.well in use-. : .Theiabove <br /> information is true to- the-best-of my knowledge and belief. I-WILL CAL—FOR A GROUT INSPECTION I <br /> PRIOR-TO G OUTING AND FINAL INSPECTION. _ i <br /> SIGNED TITLE f� r <br /> DRAW PLOT- PLAN-ON•REVERSE-SIDE �-- -• w - - <br /> PHASE I <br /> FOR DEPARTMENT-USE ONLY - <br /> � <br /> APPLICATION ACCEPTED 8Y r £DATE <br /> ADDITIONAL COMMENTS.•. t <br /> PHASE .II GROUT INSPECTION ~' PHASV III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> r .._ % <br /> E H 1426 Rev.' 1-74' 1... 7e, 0u i <br /> r' <br />