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SAN JOAQUIN LOCAL, HEALTH DISTRICT Z/7 <br /> FOR OFPICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-P <br /> k THIS PERMIT EXPIRES I, YEAR FROM DATE ISSUED <br /> Date Issued -_77 <br /> (Complete In Triplicate) /l <br /> Application is Aereby 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 /> Relations of the. Sa <br /> County Ordinance _No.-1$62-and .the Rules and Reguln Joaquin Local Health Distr' .ct. <br /> `1�6 3­S. tl�z_4.J.,q�E <br /> JOB ADDRESS/LOCATION- <br /> LAI <br /> �SULWACT <br /> i Owner's Name - <br /> Phone <br /> Address <br /> City <br /> Contractor's Name r <br /> < License ��, -//,!! Phone <br /> -TYPE�-OF-WORK"(Check) t`'rNEW WELD / DEEPEN _ <br /> /�/ 'PRECONDITION /_� ` DESTRUCTION <br /> PUMP INSTAL TION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> i F Other .� <br />} DISTANCE TO NEAREST: SEPTIC LSEWER LINES �-- <br /> PIT PRIVY <br /> SEWAGE DISPOSAL �j CESSPOOL/SEE?AGE PIT -�_ OTHER <br /> INTENDED USE <br /> PROPERTY LI ATE DOMESTIC WELL _-f PUBLIC DOMESTIC WELL- <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />€ Industrial <br /> _ Cable Tool Dia, of Well Excavation < <br /> Domestic/private Drilled . Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation /Q <br /> ,L �4 ,.,X/ <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal. Other _ Other Information <br /> Geophysical Surface Seal In <br /> stalled B <br /> PUMP INSTALLATION: Contractor V.� '' 5 "�'�"' 3 �7 <br /> T e of Pum <br /> YP P 7ihAAH.P. Y <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP_:REPAIR:, ,,/4 State WorkT _ <br /> Done. <br /> DESTRUCTION OF WELL: We11 'Diamet6r - <br /> `' ' ' _Describe .Material and- Procedure -- Approximate Depth <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 <br /> information is true to t e b t o Putting the well in .use. The above <br /> PRIOR T .knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> IN D A N I � <br /> SIGNED <br /> TITLE 00, <br /> (]DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE �7 <br /> PHASE II GROUT INSPECTION PHASE I/FIN. INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> DATE p <br /> E H 1426 <br />