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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: ! 1601 E. Hazelton Ave. , Stockton, Calif. } <br /> I� Telephone: (209) 466-6781 <br /> - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. «Y?7--35?it/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _Z77 <br /> j� (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. <br /> JOB ADDRESS/LOCATION yO c <br /> CENSUS TRACT <br /> Owner's Name - �� Phone 3 <br /> I� <br /> Address 3 [� City O <br /> Contractor's Name ® � License (� x,37 Phona3CP4_ 9 <br /> iI <br /> TYPE OF WORK {Check} ; NEW jWELL /_7 DEEPEN ffiRECONDITION DESTRUCTION /_7 <br /> PUMP 'INSTALLATION I I PUMP REPAIR / I PUMP REPLACEMENT /7 ' <br /> other L-1 , <br /> IN � <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 � I <br /> Industrial Cable Tool Dia. of Well ExcavationI <br /> Domestic/private Drilled Dia. of Well Casing �- <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal \1 <br /> - Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal. Installed By: i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ` H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done <br /> i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> jM <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 Distri,pt a <br /> WELL DRILLERS REPORT of the well and notify them before putting the.-yell in use. The above <br /> information is true to the best of my- knowledge and belief. I WILL CALL FOR A GROUT INSPECTIOR <br /> PRIOR TOG TIU AND 6 XkMAL INSP CTION. <br /> SIGNED TITLE <br /> fi Ld P + PLAN ON kSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUZ INSPECTION PHASE. I I FINAL INSPECTIONS . <br /> INSPECTION BY .11 DATE INSPECTION BY DATE -//-7 <br /> 3/ 6 2MK <br /> E H 1426 Rev. 1-74 <br />