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V1601 <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOEOFFICE USE: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 - <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _Z-.1 �6. <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 a San Joaquin Local Health District. , <br /> JOB ADDRESS/LOCATION ! CENSUS TRACT <br /> Phone <br /> Owner's Name � W <br /> city <br /> Address Q <br /> Contractor's Name R <br /> License;? tPhone <br /> -z <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN/ / RECONDITION -7 DESTRUCTION T <br /> PUMP INSTALLATION I I PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL,FIELD r CESSPOOLJSEEPAGE PIT OTHER <br /> M n 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 t Dia. of Well Casing �! <br /> .Di7 en "k Gauge of Casing_ <br /> domestic/Public .� <br /> Irrigation °Gravel Pack`r�t Depth of Grout Seal \ . <br /> Cathodic Protection Rotary ?. Type of Grout <br /> Disposal Other 'Other Information <br /> Geophysical p Surface Seal Installed By:. <br /> e <br /> PUMP_ INSTALLATION: Contractor - <br /> H.P. <br /> Type of Pump = <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / <br /> State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter" <br /> Describe Material and Procedure <br /> I hereby agree to comply- with all laws and regulations of the San Joaquin Local Health District <br /> T and�theState_of Calif oriiia_pertaining-mto�ory--regulating. well�constr-uction. -Within�FIFTEEN' DAYS <br /> after completion of~my work on a new well, I will furnish the San Joaquin Local Health District <br /> the well in use. The above <br /> WELL DRILLERS REPORT of the well and notify them before putting <br /> information is true to the best of my knowledge and belief. I WILL CAL OR A GROUT INSPECTION <br /> PRIOR TO GR TING ANDk4jWjAl NSPECT ON. <br /> SIGNED TITLE <br /> 1 ! <br /> DW PL T PLAN ON REVERSE SID <br /> DEPART USE ONLY <br /> I r <br /> PHASE I Gtl1�54►� DATE 9` Z3 ' Zb - - <br /> APPLICATION ACCEPT <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION F E / .INAL INSPECT 0 <br /> INSPECTION BY DATE INSPECTION B DATE <br /> � <br /> 3/7b 2M <br /> 26 Rev. 1-74 <br /> E H 14 <br />