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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,OFFI E USE:. 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.Y /? <br /> THIS PERMIT EXPIRES 1 YEAR• FROM DATE ISSUED Date Issued _/s 77; � <br /> (Complete Irf 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 Sari Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION w CENSUS TRACT ,k <br /> / 7 <br /> Owners Name l JQ d CJ _ Phone <br /> Address �` .`�� "`.' G%1��e4�' K/- City <br /> Contractor's NLicense # Phone <br /> r <br /> LZ <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION / `/ DESTRUCTION /-7 <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 <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 _ 4 <br /> Irrigation Gravel Pack Depth ...o,f Grout' Seal <br /> Cathodic Protection Rotary "Type of Grout <br /> Disposal Other- Other Information ' <br /> Geophysical Surface ,Seal Ifist•a11ed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 1' H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ..REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f <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 kno ladg and be ef. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G TING AND A FINAL I S 0 . <br /> SIGNED <br /> TLE <br /> ( V LOT Ph ON RSE SIDE) <br /> PHASE I <br /> R. DEPARTMENT USE ONLY <br /> �� . <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br />' PHASP II G OUT.-'TNSPECTION . PHASE III/FINAL INSPECTION- <br /> INSPECTION BY� DATE. INSPECTION BY DATE ",7CQ <br /> 1 <br /> 1177 . <br /> E H 1426 Rev. 1-74 r , _ <br />