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SAN JOAQUIN LOCAL. HEALTH DISTRICT j <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , .,Stockton, Calif. <br /> Telephone: (209,) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> .ala 10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> Cmy Ordinance No.. 1862 and the Rules and Regulations of. the San Joaquin Local Health District. <br /> I7 - i <br /> JOB('ADDRESS/LOCATIONJ. CENSUS TRACT <br />'r Owner's Name Phone ' <br /> Address ` <br /> w0 City ' <br /> Contractor's Name 4,te votu License Phone q <br /> TYPE OF WORK (Check) : NEW WELL/ J DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /47— <br /> ,i/ 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 TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation CA <br /> Domestic/private Drilled Dia, of Well Casing (off <br /> Domestic/public Driven Gauge of Casing ` <br /> _A� Irrigation Gravel Pack Depth -of Grout Seal �. <br /> Cathodic Protection Rotary Type of Grout ...,', ti <br /> Disposal Other <br /> � .. Othear,ceInformation <br /> - =Geo h sl-ca1 � `Surf <br /> - - <br /> Seal'lInstalled'B <br /> PUMP INSTALLATION: Contractor Ug c tre R SA --m 4 ,C 6 <br /> �-- - - r1- Type-of Pump �- - Tsoi7ptr�� ,.�^ .,..,,_.,_..,.. .,_. H.P. l <br /> -P,IJMP REPLACEMENT: / / State Work Done4r� o <br />� PUMP :REPAIR: / / `State Work Done - <br />'pES.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 Sari Joaquin Local Health bistrict <br /> and the State of California pertaining to or regulatingwell '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 GROUTING AND A FINAL INSPECTION, <br /> SIGNED TITLE i <br /> t (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1 <br /> APPLICATION ACCEPTEDBY DATE <br /> ADDITIONAL COMMENTS:t <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _AZ7 DATE • ` '77 <br /> E H 1426 Rev. 1-74 e.e'r UZ7 2M <br />