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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. 7 7f Ldp <br /> ,THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> / (Complete In Triplicate) f <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 D(� °�' � $ CENSUS TRACT h <br /> Owner's Name � tp-*�' :j' ----- Phone <br /> Address. d � ¢ City <br /> License # Phone ; <br /> i1 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATIONPUMP REPAIR /—/ PUMP REPLACEMENT f_1 <br /> Other / / <br /> DISTANCE TO 'NEARMT. SEfTIC 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 N <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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 Pump H.P. <br /> PUMP REPLACEMENT: .. / / State Work Done w • . <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter95� 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 k <br /> after completion of my. workon,aa:new well, I will furnish the San Joaquin Local Health District- a <br /> WELL DRILLERS REPORT 'of tihe_well-and notify them before putting thewellin use. The above <br /> information is Arue to the-best of. my. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT4XG AND <br /> SIGNED E TITLE 4-44'PeWO'° <br /> (DEW-POT TPLAN 'ON REVERSE SIDE ; r ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY DATE /Z/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II QROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY . DATE -X-,7 <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />