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t SAN JOAQUIN LOCALHEALTH DISTRICT <br /> FOE:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 9 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. lv W <br /> # <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaquil <br /> County Ordinance No, 1862 and the Rules and -Regulati.ons of -the San Joa u n..Local Health District. <br /> JOB ADDRESS/LOCATION - ZZO CENSUS TRACT , <br /> Owner's Name Phone ,?- 1/ <br /> r <br /> Address City ' <br /> Contractor's Name '64'a L4LLicense # Phone _-5Z- Z <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> f PUMP INSTALLATION -/ / PUMP REPAIR'/-7PUMP REPLACEMENT_ /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY d <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 N `' <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven w Gauge of Casing A/69 <br /> k/ Irrigation Gravel Pack Depth of Grout Seal r <br /> Cathodic Protection - Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal InstaeV <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:, ' / / State Work Done <br /> �. PUMP' ;.REPAIR: i / / State Work Done <br /> DIS•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 /> f and the State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> after completion ofy 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.,iri".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 GR UTING AND tINSPMI-ON., , <br /> SIGNED TITLE Ccs <br /> --{DRAW &JOT PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> ` APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE _I-W/FIN`a INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - <br /> E H 1426 Rpv. 1-74 / ✓ h/75 2M <br />