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SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOR OFFICE-USE: cf 160 . E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 lJ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,P- <br /> P-V—/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued � _� <br /> (Complete In Triplicate) <br /> Application is hereby made to Ythe San Joaquin Local Health District for a permit to construct <br /> Joaquin <br /> and/or install the work herein described. This application is made in compliance with San <br /> County Ordinance No. 1862 and <br /> the fund�jt�egA i of the an JoaquinLocal e h District. <br /> J C': CENSUS TRACT <br /> JOB ADDRESS/LOCATION Ia�2 am/V <br /> .�7'��'tl� ►r .� Phone <br /> Owner's Name <br /> City <br /> Address <br /> Y <br /> License # Phone <br /> Contractor's Name ; <br /> TYPE OF WORK (Check).: NEW WELL DEEPEN '/ / RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT 1_7 <br /> Other <br /> PTIC TANK SEWER L NE PIT PRIVY <br /> DISTANCE TO NEAREST:' OTHER <br />'t A 'SEWAGE DISP SAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE -' PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS {. i <br /> Industrial Cable Tool Dia. of Well Excavation �� <br /> rivate Drilled Dia. of Well Casing <br /> Domestic/p Gau e,ofCasin - <br /> _ - -Domestic/public -- Driven .--. � g g <br /> j. <br /> Irrigation Gravel Pack 'Depth of Grout Seal . <br /> Cathodic Protection °Rotary Type of Grout <br /> Disposal. Other Other Information 9 <br /> Geophysical. Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done 4 <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter, <br /> _ <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 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND FINAL INSPECTION• TITLE <br /> SIGNED <br /> D :PP <br /> FORPLAN ON REVERSE 5I11 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 3' -77 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PRASE /FIN INSPECTION <br /> P TI GRO T INSPECTION INSPECTION BY DATE -7INSPECTION BY DATE <br /> i 3/76 2M <br /> �'.° F U 1 L9A Rev. 1-74 <br />