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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUNT PERMIT Permit No.,,Y- 3.55-5' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2-Z-,;7-.2r <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 lv S -•� CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address 6 -s ,- <br /> City <br /> Contractor's Name <br /> License ��`��� phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / / DESTRUCTION /'7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPL EMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTEPROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> NDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' <br /> 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 /> N. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information o <br /> Geophysical Surface Seal Installed B : 4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 />'RIOR TO GROUTING AND,# FINAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) �_. <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY g� <br /> ADDITIONAL COMMENTS: DATE / <br /> PHASE II GROUT INSPEC ON PHAS III/F NAL INSPECTION {r <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rey. -74 6/77 Ans <br />