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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209) 466-6781. R <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/6-4/-.7 <br /> ' I (Complete In Triplicate) . <br /> Application is Aereby 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 ADD&S/LOCATION <br /> � CENSUS TRACT <br /> Owner's Name Phone <br /> Address /Q City , <br /> Contractor's Name License ���Dg Phone <br /> TYPE OF WORK (Check) : NEW WELL IAI-�DEEPENIJ RECONDITION /_� DESTRUCTION /-7 <br /> ' PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT J� <br /> Other/ J <br /> DISTANCE TO NEAREST: SEPTIC TANK R LINES �IT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> 4—CESSPOOL/SEEPAGE, PIT OTHER ---- Q <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL -----PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS , <br /> Ir�ustrial f Cable Tbol Dia. of Well Excavation // <br /> r' Domestic/private : 1, ..,Drilled Dia. of Well Casing <br /> -+ ic Domestpublic Driven Gauge of Casing _ <br /> ,: -�- <br /> ~Irrigation • Gra _el' Padk -Depth 'of"Grout„`-Sea- <br /> Cathodic Protection .,8.tary- d Type of Grout <br /> Disposal Other Other Information <br /> Geophysical "'"Surf-a, Seal Installed`"B r <br /> PUMP INSTALLATION: Contractor <br /> Type of PumKL I PC H.P.- <br /> , <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter r •. Approximate Depth <br /> Describe Material and Procedure <br /> 1 <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 /> t 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 /> inf ation is true to t f my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR ROUTING D 5 ON. <br /> ' SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> 1 FOR DEP TMENT USE ONLY <br /> PHASE l <br /> APPLICATION 4C�EPTED BY / DATE fd l- 7Y <br /> ADDITIONAL CbMMENTS: <br /> \P�SE jI. GRgUT INSPECTION PHASE IT FINAL NSPECTI N <br /> 1. INSPECTION BY DATE 0 447� _ INSPECTION BY ATE / <br /> / 5 P�trvY,-w arn, �' t , tE H 1426 Rev. 1-74 '�"l .. Yr911,1v �"'�' f'"""�f 77 29 <br />