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A <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> R <br /> FOOFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. 5 <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -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 nd the Rules and Regulations of the Sa J again Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address ,�_ City -G . <br /> Contractor's Nam n i-� � License 0064"ao Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN/ / RECONDITION / / DESTRUCTION f� <br /> PUMP- INSTALLATION / / PUMP REPAIR / I PUMP REPLACEMENT <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 /> 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 Instt�allled B : - <br /> PUMP INSTALLATION: Cr6r��- �1 dry <br /> Type of Pump H.P. <br /> tiPUMP REPLACEMENT: State Work Donee gone <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 /> I' 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 C OR A GROUT INSPECTION <br /> PRIOR TO G UTING AN 4nFINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW� PL T PLAN 'ON KNE <br /> SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /__:Z/-77 <br /> ADDITIONAL COMMENTS: OF <br /> PHASE I ROUT, INSPECTION PHAS II/F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE /-2 _ZZ_ <br /> .. <br /> k E H 1426 Rev. 1-74 3/76 2M <br />