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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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g <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. 1662 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> ///,5-1 N WEST" - r +�O"L/_ 0S? - Qso os <br /> JOB ADDRESS/LOCATION ;4 ,C 4-2 CENSUS TRACT <br /> Owner's Name -- <br /> �- Phone J 0 14L( <br /> Address f 3 City <br /> Contractor's Name License Phone 3 6 L4 24 <br /> TYPE OF WORK (Check) : , NEW WELL/_7 DEEPEN /_7 RECONDITION DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR -j3R''PPUMP REPLACEMENT f7 <br /> Other /_7 trZ <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 TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool .'Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing r <br /> Irrigation 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 Pumper H.P. <br /> PUMP REPLACEMENT!: / / State Work Done. <br /> PUMPIREPAIR: / State Work Done �` x <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 before putting. the..well. in.use.., The above; <br /> information is true to the best.of- y. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G AND AL INSPE ION. <br /> SIGNED TITLE <br /> ILQRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -// <br /> ADDITIONAL COMMENTS: i2 �,^. <br /> PHASE II GROUT INSPECTION PHASE III NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4-e - DATE vS'=^/jn;-7 j <br />` E H 1426 Rev. 144 4/75 2M <br />