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C SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1rOF� OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7;z.7Ujz <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE-ISSUED Date Issued )L- <br /> (Complete <br /> -(Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> end/or install the work herein described. This application is made in compliance with San Joaquiaat <br /> County Ordinance No. 1862 and the'Rulen and Regulation* of the Son -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION N_ CtsUS TRACT <br /> Owner'a Name Phone , l�� <br /> Address <br /> City ' <br /> Contractor's Name <br /> License 'Phone <br /> TYPE OF WORK (Check): NEW WELL'L7 DEEPEN '/f. PRECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION L-7 PUMP REPAIR /-7 PUMP REPLACBMENT <br /> Other L-? <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE lO TIC L PUBLIC MSTIC <br /> INTENDED USE '1RPE OF MLL CONSTRUCTION SPECIFICATIONS <br /> Industrial _r_A,.,' al*Tool Dia. of Well Excavation <br />,,,�-, Domestic/private Drilled Dia. of Well Casing �f <br /> stic/public Driven Gauge of Casing <br /> -.- Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection - Rotary Type of Grout <br />______Disposal Others Other Information <br /> Geophysical Sumacs SgA,'l ailed�8v <br /> PUMP INSTALLATIONt Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: S� State Work Done <br /> M -REPAIR: S tat"47 Work Done <br /> "�. <br /> EDF TTRUCT ION OF WELL: Well Diaereter Approximate Depth <br /> Descr be 'k,aterial 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 FIFTEENDAYS <br /> after completion of my work on anew 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 GRQUTING A l A IFINAL-INSpscrIoN. <br /> SIGNED _ TITLE <br /> DRAW PLOT PLAN W REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPS ION ACCEPTED BY C DATE <br /> ADDITIONAL COMMENTS <br /> PHASE II GRAFT INSPACGT F III . E <br /> INSPECTION BY DATZ INSPECTION BV, D= z� � <br /> E H 1426 Rev. 1-74 h/75 9m <br />