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O / <br /> SAN JOAQUIN LOGS -HfALTH DISTRICT <br /> FOF *OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ITelephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75--S�tJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is 1ereby made to the San Joaquin Local Health District istrict for a permitto 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 /> a <br /> JOB ADDRESS/LOCATION / ( `t1t1 CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> City � - <br /> Contractor's Name License #42d&Phone c522-/%-? <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/? RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/-7—PUMP REPLACEMENT f7 --Q <br /> Other /? <br /> 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 06 <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 /> t--Domestic/private 'Drilled Dia. of Well Casing • <br /> Domestic/public Driven Gauge of Casing j <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 <br /> Type of Pump A.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP ,REPAIR: /-7 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 the well and notify them before putting- the-well in use- The above <br /> information is true to the, est of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG UTING AND A F INSPE ON. . <br /> SIGNED - TITLE <br /> LO LAN REVERSE SIDE <br /> PHASE I 4 <br /> RLOEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS <br /> PHASE I GROUT INSPECTION P FINAL INSPECTION <br /> INSPECTION BY DATECA-)S-15- INSPECTION BY DATE - 5-7 s <br /> E H 1426 Rev. 1-74 �� °�' �� ~ <br />