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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> EOF .OFFICE USE: ' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> �- APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 ` <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued `y <br /> (Complete In Triplicate) <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 /> County Ordinance No. 1862 and the. Rules and Regulations of the San Joaquin Local Health Distr�c.t. <br /> JOB ADDRESS/LOCATION , r� ## <br /> CENSUS TRACT � I <br /> Owner's Name <br /> r Ccr vs� Gi Phone ' <br /> Address <br /> City J <br /> Contractor's Name 4�; .License V92 Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /% 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 <br /> TYPE OF WELL r CONSTRUCTION SPECIFICATIONS <br /> Industrial CablewTo`ol'-' Dia. of Well Exca'vaf ori'• ® ' <br /> Domestic/private Drilled % Dia, of Well Casing <br /> Domestic/public Driv'e.n Gauge of Casing <br /> Irrigation Gravel 'Pack Depth of Grout Seal � x <br /> Cathodic Protect_ ion -- ;Rotary Typeof Grout <br /> Disposal -Other -- <br /> Other Information <br /> Geophysical <br /> Surface Seal Installed By: jc <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. . . <br /> PUMP REPLACEMENT: / / State Work Done . <br /> PUMP -.REPAIR: / / State Work Done ' <br />)ES•TRUCTION. OF WELL: Well Diameterr AppzoximateDepth <br /> Describe Material and Procedure= <br /> I hereby agree to comply with all laws and regulations of the San Joaquin—Local Hey-ith. I3istr t ' <br /> and the State of California pertaining to or regulating well construc ion: Withini FIFTEEN DA <br /> after completion of my work on a''new well, I will furnish the San Joaquin Loral Health District <br /> WELL DRILLERS REPORT of we11 and notify them 'be'fore ' `' -?--" ` <br /> Information is tr o the best of m Y puttin.gtkie .we 11 _.L use. The above <br /> MY owledge andibelief. I WILL .CA% � FOR A GROUT INSPECTION. <br /> LRRTO GROUT '� �` ' <br /> �= TITLE ` <br /> (DRAW PLOT-PLAN_ ON�REVERSE SIDE) <br />?RASE I FOR DEPARTMENT -USE ONLY I <br /> OPLICATION ACCEPTED BY- ., E <br /> DATE <br /> IDDITIONAL COMMENTS: s <br /> PHASE II GROUT INSPECTION PHASF, _kIj/RZVAL INSPECTION <br /> CNSPECTION B DATT.E�, INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 v 1/77 ' 2M <br />