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v SAN JOAQUIN -LOCAL HEALTH DISTRICT <br /> FORi OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 17 Telephones (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 75 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued f-,2- <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-4 <br /> JOB ADDRESS/LOCATION " ,. ` . CENSUS TRACT <br /> Owner's Name ' a'� Phone <br /> -.w , <br /> Address *� �' .. ks' �, City _ <br /> Contractor's Name , _ " t - '}� _� - - Licensa__1. ` Phoneme <br /> : <br /> �. <br /> TYPE OF WORK-(Check) NEW+>WELL'../ ?EEPEN '/� RECONDITION /_� DESTRUCTION � <br /> PUMP'<INSTALLATION PUMP REPAIR /7 PUMP REPLACEMENT /? d"- <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES kPIT PRIVY <br /> SEWAGE DISPOSAL. FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> G PROPERTY LINE"'="PRIVATE-DOMESTI-CTWELU"' , PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable fool Dia. of Well Excavation �j <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public t Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seaf <br /> Cathodic Protection E Rotary -. - ..Type--of 4_201 <br /> Disposal ' Other Other Information } <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump" H.P. r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR:, /=7�-State Work Done .. ... , <br /> IDES'TRUCTION OF WELL: Well Diameter 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 <br /> after completion of my work on anew 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 knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> fPRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I <br /> APPLICATION ACCEPTED BY C. DATE 7 <br /> ADDITIONAL COMMENTS:. <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE 9s� INSPECTION.BY DATE <br /> l E H 1426 Rev. 1-74 1-74 2M — <br />