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7,. <br /> S SCANNED <br /> AN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.7 FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75-1,�SDLd <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Como late 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 l ,�d - e Tf �`,yl,��, �#�L �� ENSUS TRACT <br /> Owner's Namec, <br /> Phone ps s <br /> Address City <br /> Contractor's Name License � iS Phone <br /> TYPE OF WORK (Check)s NEW WELL. DEEPEN/7 RECONDITION /? DESTRUCTION /-7 <br /> PUMP INSTALLATION/7 PUMP REPAIR/_7 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 /> V_ Domestic/private Drilled Dia. of Well Casing ��� . <br /> Domestic/public Driven Gauge of Casing /? 461V <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information a <br /> Geophysical Surface Seal Installed BX: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP I.REPAIR: /7 State Work Dane -- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> N <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 alcove <br /> information is true to the-best.of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING•AND INS ION <br /> SIGNED ITLE , <br /> DRAW T P N E SIDE <br /> EP T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY SPECTION BY DATE <br /> E x 1426 '�• <br />