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SCAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> OR <br /> F .OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 - 00 <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. 1862 and the Rules and Regulations of the San Joaquin Local Health Distr#ct. <br /> JOB ADDRESS/LOCATION V ��/ ,� ��`y, T�-G CENSUS TRACT <br /> Owner s Name ` fir,�, s /�c� a t-✓ Phone <br /> Address .�.��_. City <br /> Contractor's Name ��� /�*,�.,��s Licenseq� � -Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION /R PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SE A�,GE 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 ze <br /> Domestic/private Drilled Dia. of Well Casing 'Wil'Wile- <br /> Domestic/public Driven Gauge of Casing 2) <br /> Irrigation Gravel Pack Depth of Grout Seal O <br /> Cathodic Protection _ Rotary Type of Grout L_Disposal Other Other Other Information <br /> Geophysical Surface Seal Installed By: Q Cc-G <br /> PUMP INSTALLATION: Contractor <br /> TYPe jf Pump 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 REPORT of t--well and notify them before putting the well in use. The above <br /> information is true t the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU N TI , <br /> SIGNEDE'`ZtL� TITLE L_ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE T- AZ-7. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 1 DATE ,._` '/I d , <br /> l r <br /> 1177 2M <br /> E H 1426 _ Rev. -74 <br />