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` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601_ E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: ' (209) 466--678 . p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L29-77 <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 �? Q j Qr y� CENSUS TRACT t <br /> I' <br /> Owner's Name •-% Phone <br /> Address City <br /> Contractor's Name � �n � �r�_- _- License # Phone <br /> _ d <br /> TYPE OF WORK (Check) : NEW WELL '/—/ DEEPEN '/_/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> r SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL j <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing W <br /> Domestic/public Driven Gauge of Casing`.,r .r.•. <br /> Irrigation Gravel Pack Depth of Grout,.Seal <br /> : .Cathodic Protecion, Rotary Type of <br /> Grout - <br /> Disposal Other Other Information ! <br /> Geophysical Surface Seal Installed By: <br /> PUMP INStALLATION: Contractor <br /> Type of Pump H.P. <br /> a <br /> PUMP REPLACEMENT / / State Work Done , <br /> PUMP ,.REPAIR: / / State Work Done f <br /> I <br /> f <br /> DESTRUCTION OF WELL: ".Well Diameter' Approximate Depth <br /> Describe Material and Procedure <br /> P 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 we11 '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 GROUTZVG AND A FINAL NSPE TION. f <br /> SIGNED TITLE ,j,/� _ <br /> ' (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY - _- _ - DATE 7-' .2,�;Oc_7�' <br /> ADDITIONAL COMMENTS: <br /> PHASE I ROUT INSPECTION PHAS III FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY 4gDATE <br /> 1/77 . .. � 2M <br />