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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOS OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 22--#00"o <br /> THIS PERMIT EXPIRES I. YEAR FROM DATE -ISSUED Date Issued <br /> 71 <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 CENSUS TRACT <br /> Owner's Name jn& d/ 7- Phone 37 6 , <br /> Address City -M <br /> Contractor's Name .-License Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION I�T -DESTRUCTION <br /> PUMP, INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <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 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> A.— 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 1' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Al nr NNN <br /> F Type of Pump h H.PLAX <br /> . <br /> PUMP REPLACEMENT: / j State Work Done <br /> a.PUMP .REPAIR:' / / State- Work-Done <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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A 'FINAL INSPECTION. t .y 4 <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> " FOR DEPARTMENT USE ONLY <br /> [ PHASE I j s <br /> APPLICATION ACCEPTED BY DATE '� / <br /> r <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III]FINAL INSPECTION <br /> INSPECTION BYDATE - _ :INSPk CTION- B 171 _ namR � ;7�? <br /> 1/77 214E H 1426 Rev. 1-74 <br />