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SAN JOAQUIN LOCAL1dAVM DISTRICT <br /> FORrQFI'TCE USE- <br /> 1601 E. Hazelton Ave. , Stockton, Calif. r <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. = ftJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued LZZ <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 Joaquin ; <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION t Cc L& CENSUS TRACT <br /> I <br /> f <br /> Owner's Name .._ _ Phone 12 I <br /> F I <br /> Address City <br /> V <br /> Contractor's Name. LA License # I0-o701 Phone ' <br /> TYPE OF WORK (Check): NEW WELL.-R7 DEEPEN /_� RECONDITION /_� DESTRUCTION , <br /> PUMP INSTALLATION /_/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES =' , _PIT PRIVY i <br /> SEWAGE DISPOS�IEI;D ' CESSPOOL/.SEEPAGE PIT OTHER F <br /> PROPERTY LINE _ PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL A Ii <br /> INTENDED USE TYPE OF WE CONSTRUCTION SPECIFICATIONS r <br /> Industrial -� Cable Tool �.. Dia. of Well Excavation <br /> Domestic/private ; Drilled � .Dia. of Well. Casing <br /> _ Domestic/public Driven Y � Gauge of Casing <br /> _ Irrigation Gravel Pack Depth of Grout Seal 6-.2 4- <br /> Cathodic Protection Rotary Type of GroutCe <br /> Disposal. Other Otlier"-Information <br /> Geophysical _ 7 Surfade Seal. Installed ; <br /> PUMP INSTALLATION: Contractor ."`•. � �. 4 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP_REPAIR: State Work Done, - ` <br /> ES+TRUCTION 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 Di-etrict <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.! an Joaquin Local .Health Di Cr4:EC 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 CAIi FOR_A-GROUT� SPECTIQN <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED t TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE •, y <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I t <br /> APPLICATION ACCEPTED BY � t DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS & I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION- BY _ DATE ! <br /> �� E H 1426 Rev. 1-74 1-74 9M <br />