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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: I.601-E. .Hazelton Ave, , Stockton, Calif. <br /> j - Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued O-7lo <br /> (Complete In Triplicate) <br /> Application is hereby 'made tofthe 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 /> JOB ADDRESS/LOCATION „ MZ1261 / �� .L, �•^ y'r'z� CENSUS TRACT <br /> 1.1 <br /> Owner's Name 1 Phone S ! <br /> Address 2 7 7 6 6 � City <br /> Contractors Name <br /> License # Phone . <br /> TYPE OF WORK (Check) : NEW WELL -// DEEPEN '17 RECONDITION fT DESTRUCTION <br /> . PUMP INSTALLATION / / PUMP REPAIR'/ P _ <br /> Other 7 R/ / <br /> DISTANCE JO NEAREST: SEPTIC :TANK SEWER LINES PIT PRIVY <br /> SEWAGE-DISPOSAL FIELD CESSPOOL/SEEPAGE PITOTHER <br /> PROPERTY LINE •- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL Q <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. of Well Excavation V <br /> E Domestic/private t Drilled Dia. of Well Casing <br /> Domestic/public :` Driven Gauge of Casing <br /> Irrigation 1- Gravel Pack Depth of Grout Seal <br /> f Cathodic Protection j Rotary Type of Grout ' <br /> Disposal i Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> f PUMP INSTALLATION'. Contractor <br /> Type jof Pump R.P. <br /> I <br /> PUMP REPLACEMENT: • / / Estate Work Done <br /> PUMP ,,REPAIR: / / +State Work Done <br /> ... .. r <br /> bES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia and Procedure <br /> f 'J <br /> I herebagree o comply with all laws and regulations of the San Jaa uin Local Health District <br /> ,and the State of California,pertaining to or regulating well"construct on. 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.:wel1 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 GR U I G AYD A F NAL INSPECTION. <br /> 'SIGNS TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> E ( <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ' APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT:INSPECTION PHA 1tI INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY TE <br /> 2M <br /> tt u 1L9r, De I_74 <br />