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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR. FICE USE: 1601 E. Hazelton Ave, , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '79-7/7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedfo <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 /> County Ordinance No. 1862• and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCA ON/ ' /n CENSUS TRACT <br /> Owner's Name Phone <br /> • <br /> Address , City <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check) , NEW WELL/ / DEEPEN RECONDITION RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION f PUMP REPAIR /—/ 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 DOMESTI WELL <br /> INTENDED USE TYPE OF WELL, CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 1 Domestic/private Drilled Dia. of Well Casing <br /> �_�omestic/public Driven Gauge of Casing <br /> V_ Irrigation Gravel Pack Depth-.of- Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface S. al Installed By: <br /> PUMP INSTALLATION: Contractor K' <br /> Type of Pump V H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP •.REPAIR: / / State Work Done <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 REP RT of the well and notify them before putting the..well in use. The above <br /> information a to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G AV A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 45 .2 45-/? <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/ ICTAL INS#�ECT ON <br /> INSPECTION BY DATE INSPECTION BY f DATE 7 <br /> E H 1426 Rev. 1-74 ' 11.77 2M <br />