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/ SAN JOAQUIN LOCAL 'HgALTH.DISTRICT <br /> FOhiOFFICE USE: r` 1601 E. Hazelton Ave.', Stockton, Calif. <br /> Telephone., " (209) 466-6781 + { <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74(-,,Q g 41, . <br /> THIS PERMIT EXPIRES I YEAR FROM,DATE ISSUED Date Issued/ -�-��- <br /> (Complete IntTriplicate) <br /> Application' is hereby made to the San Joaquiu,.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 = SR.� ENSUS TRACT <br /> Owner's Name Phone <br /> �J � c <br /> Address "'. / Y' City <br /> Contractor's Name _ License �� '�. Phone -7C� 'C <br />'E <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN/_ RECONDITION F7 DESTRUCTION 17 <br /> P REPLACEMENT <br /> PUMP <br /> INSTALLATION PUMP REPAIR <br /> REPAIR /� UMP <br /> 1 �/ <br /> Other 1 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER v <br /> i PROPERTY LINE -- PRIVATE DOMESTIC WELL ' - PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial z---Gable Tool Dia. of Well. Excavation <br /> t�osticjprivate Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal Q <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal _ Other Other Information <br /> Geophysical ;._ Surface Seal Installed By: <br /> PUMP .INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PW4P REPLACEMENT: % / State Work Done <br /> PUMP `.REPAIR: /7 State Work Done <br /> ,RES;TRUCTION 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 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 GRORTIN0, 64D A FINAL SPECT ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> -- FOR. DEPARTMENT USE ONLY - <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> lINSPECTION BY ,ter DATE - INSPECTION BY DATE - 1Z.7 ,.�� <br /> E S 1426 Rev. 1-74 1774 2f77- <br /> - <br />