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Ca' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE SE: 101 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> •''P APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7—=a � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin'Loca1 Health District for a permit to construct <br /> and/or insj'tall 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. <br /> 1 <br /> JOB ADDRESS/LOCATION CENSUS TRACT ; <br /> Owner's Name �. c - „- --- - Phone <br /> Address City i <br /> Contracto l s Name License #/: .37W Phone L 74 I <br /> i <br /> TYPE. OF WT (Check) : NEW WELL / / DEEPEN-/ % RECONDITION- /-. DESTRUCTION /-7 4 <br /> PUMP INSTALLATION / / PUMP REPAIR.'/fit/-PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 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 Dia. of Well Casing I <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal , <br /> Catli1odic Protection Rotary Type of Grout <br /> Disposal Other t Other Information <br /> Geophysical ! Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of: Pump �7�r, : H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: 1State Work Done <br /> DES,TRUCTIOIN 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 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 UTING AND A FT �1L I SPE ION.. <br /> I <br /> SIGNE ' t' 2jj TITLE - <br /> '(143^ PLOT PLANVN REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ^ZI <br /> ADDITIONAL COMMENTS: T— <br /> l! PHASE II GROUT I ION PHAS 41/FINAL INSPECTION <br /> INSPECTIO BYDATE INSPECTION BY DATE <br /> 376 2M <br /> E H 1426 Rev. 1-74 <br />