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c� 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. <br /> 76 la A, <br /> THIS PERMIT EXPIRES l 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 5 7 7 7 i CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br /> City ,- <br /> r <br /> Contractor's Name License # q4Z4jaLPhone <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN '/_? RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /Fj PUMP REPAIR/7 PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK Z10 , SEWER LINES /c2 1_ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL: 2..i=-' 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 Casing �1 <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 - �I <br /> Geophysical Surface Seal Installed 'B : �1r/kCr <br /> PUMP INSTALLATION: s <br /> Contractor <br /> Type of Pump H.P. 1 <br /> PUMP REPLACEMENT: . %/ State Work Done <br /> PUMP :REPAIR: / / State Work Done <br /> DBS-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> T 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 furnish 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 to the-best.of. my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIW AND A FINAL INSPECTION. <br /> SIGNED ZZ,4e, TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPART MEN I USE ONLY <br /> PHASE I �� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 55177 <br /> E H 1426 Rev. 1-74 !' _ h/75 2M <br />