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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFI USE: } 1601 E. ,Hazelton Ave. , Stockton,- Calif. <br /> Telephone : (209) 466-6781 �) f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ' Permit No. �d1 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued 3­6771 <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 Joaquin <br /> County Ordinance No. -1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB yADDRSSOCON � / f CEN <br /> SUS®TRACT <br /> Owner's Name QPhone <br /> f <br /> Address42 <br /> City <br /> f Contractor's Name <br /> License # e Phone �� <br /> TYPE OF WORK (Check) : NEW WELL / DEEPENr / / RECONDITION /�/ DESTRUCTION '/?; <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK f. SEWER LINES PIT PRIVY 11 <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 w <br /> Industrial able Tool Dia. of Well Excavation � <br /> ' ��Domestic/private Drilled Dia. of Well Casing � <br /> k Domestic/public Driven Gauge of Casing CA _ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> t Cathodic Protection Rotary Type of Grout D <br /> Disposal Other Other Information <br /> '- Geophysical Surface Seal Installed By: <br /> a` <br /> PUMP INSTALLATION: '` Contractor <br /> Type'of Pump ., e. - - -- H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> UMP -.REPAIR: / / State Work Done <br /> DESTRUCTION 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 illy"workron a new wall, I will furnish the San Joaquin Local Health District a <br /> : WELL DRILLERS REPORT of the -iaell and notify them before putting the well in use. The above <br /> information is true to the b t. of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUF17NG AND.A FIEAV INS ECTIQN. ' <br /> SIGNED TITLE e � � <br /> (D PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY 1 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DAA E � <br /> ADDITIONAL COMMENTS: <br /> J' PHASE II GROUT INSPECTI N PHASE IIT/FINAL INSPECTION <br /> ', if INSPECTION BY IRATE ' 3 "� <br /> INSPECTION'-,BY. - DATE <br /> 1/77 - 2M <br />