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i / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL4 FF CE USE: v 1601 E. Hazelton Ave. , Stockton, Calif. <br /> .,< Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,� A <br /> THUS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> � l <br /> JOB ADDRESS/LOCAT.ION 17 ZJ W �-L V�o CENSUS TRACT ' <br /> Owner's Name Phone <br /> - � <br /> Address f 7�� G�ft-a- � �-�'vi�6 City <br /> Contractor's NameLicense- �, �-" <br /> #� Phonery-?�( ' <br /> TYPE OF WORK (Check) ; NEW WELL/? DEEPEN 177 RECONDITION /-7 DESTRUCTION f7 <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 DiiMESTIC 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 <br /> Irrigation Gravel Pack Depth of Grout Seal i <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> - Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ,. `' ��-✓^ H.P. <br /> ..� <br /> PUMP REPLACEMENT: /-7 State Work Done • � '- =-' -' - � <br /> PUMP ,REPAIR: / State Work Done R F' <br /> F}E$TRUCTION OF WELL: Well ]Diameter �r_ "� 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 tE <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 . owledge and belief. I WILL CALL FOR A 'GROUT INSPECTION- <br /> PRIOR TO GROUTING 'ANDA FINAL, I CT <br /> SIGNED r - TITLE <br /> ' ( RA PLOT PLAN 0 'TERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE It G INSPECTION ' PHAS I I FINAL INSPECTWN <br /> INSPECTION BY ]DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 - 1/75 2M <br />