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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S- 3v� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued f---L-7J- <br /> (Complete <br /> `=at-7f(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 Aegul 5tAons of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION d <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> Address .- "cam"" City' G� <br /> Contractor's Name � License &-,64Phone <br /> TYPE OF WORK (Check): NEW WELL -/-7 DEEPEN -/-7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION /-7 PUMP REPAIR 1-7 PUMP REPLACEMENT <br /> Other /% -�- <br /> DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> s 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 Casimg <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal B <br /> PUMP INSTALLATION: Contracto L.� <br /> E;2cType of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /-7 State Work Doone <br /> ES-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 /> 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 fu nish 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 o the,best of my knowledge and belief. I WILL CAL FOR A GROUT INSP GTION <br /> PRIOR TO GROUTING AD A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY och DATE INSPECTION BY DATE <br /> 3 E H 1426 Rev. 1-74 Y_„ Its <br />