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S <br /> SACT JOAQUIN LOCAL HEALTH DISTRICT i <br /> FOEOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '_ t <br /> 77/,)< <br /> THIS 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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 0 CENSUS TRACT <br /> Owner..1s Name " Phone D a <br /> 4 <br /> Address ZC% <br /> - city <br /> Contractor's Names License # .. Phone <br />;TYPE OF WORK (Check): NEW WELL . l DEEPEN '/? RECONDITION T7 DESTRUCTION /_7 ; <br /> PUMP INSTALLATION . PUMP REPAIR 7 PUMP REPLACEMENT 17 <br /> Other <br /> t, <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES J/Q - PIT PRIVY <br /> SEWAGE DISP SAL ELD CESSPOOL/-SEEPAGE PIT -OTHER <br /> PROPERTY LINE VATE DOMESTIC WELL" ELIC D MESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial , Cable Tool iDia. of Well. Excavation <br /> Domestic/private Drilled Dia. of Well Casing ie <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack ' Depth of Grout <br /> Cathodic Protection Rotary . - <br /> ; Type of Grout 'i 2= O <br /> Disposal Other tr {3Othe7r Information <br /> GeophysicalZAI - <br /> ' ,Surface -Seal Installed 'Bv <br /> PUMP INSTALLATION: <br /> �. Type of Pump -H:P. P4 <br /> PUMP REPLACEMENT: . / / State Work Donee <br /> PW I.REPAIR: / J State Work Done <br />)ES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> R 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 sty 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-Vell. in.use.... .The above <br /> information is true. to;the best of- my- knowledge and belief. I WILL CALL FORA GROUT INSPEC IQN., s <br />'RIOR TO OUT NG AND A_.VjNAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW FLOT PLAN ON REVERSE SIR <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I .� �. <br />.kPPLICATION' ACCEPTED BY. ; `k DATE <br /> kDDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHASE II17yBU INSPECTION <br /> ENSPECTION BY DATE INSPECTION BY DATE <br /> f <br /> E H 1426 Rev.. 1-74 - :.k .. . L/75 2M <br />