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' SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Q 7 <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 District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name T_�_Y_Cy a y- Phone <br /> Address 1( City <br /> Contractor's Name, License # ZfA.711 Phone c - .76, 76 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ J RECONDITION J / DESTRUCTION /_ _ <br /> PUMP INSTALLATION / / PUMP REPAIR REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER iQ <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 /> PUMP INSTALLATION: Contractor A, - <br /> Type of Pump -- -..� /r Lff7- <br /> _ H.P. J <br /> PUMP REPLACEMENT: / / State Work Done f / <br /> PUMP .REPAIR: / State Work Done / �,� y-ex� - wa4/ Iridoll <br /> wr6104 000t wii ' rr av m/ <br /> DESTRUCTION OF WELL: Well Diameter / Approximate Depth <br /> Describe Material and Proc'ed'ure <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 furnfsh 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 a d belief. -I -WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO 0 TING AND A FINAL. IN CT' N I / <br /> SIGNED TITLE <br /> (D WLOT PLAN ON WEVfRSE SIDE) <br /> FOR DEPARTMENT USE .ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �...-�� DATE `1/A0 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY &7�0 DATE <br /> C 6/77 2M <br /> E H 1426 Rev. - 1-74 <br />