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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 <br /> THIS PERMIT EXPIRES 1 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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ice+ 129l cif,9 Rd <br /> JOB ADDRESS/LOCATION Wt , .eG 1 Vic 6,11prid6CENSUS TRACT <br /> Owner's Name �.Z Phone ail—12 T- <br /> Address City ' <br /> s <br /> Contractor's Name .41„L _ License Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/% DEEPEN RECONDITION RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /!;L� PUMP REPLACEMENT /_7 <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 TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <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 Installed By: <br /> r <br /> PUMP INSTALLATION: Contractor 4 X <br /> Type of Pump AT H.P. . 7— . . <br /> PUMP REPLACEMENT: / / State Work Done I <br /> PUMP .REPAIR: / / State Work Done lReho w,Z /� '' �. �• �, <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*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 <br /> . (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /113 '77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION ` PUA-E?Ej I INAL INSPECTION <br /> �EC70N--BY DATE INSPECTION BY W. DATE / <br /> ?b Rev. -74-_- 1177 _ 2M <br />