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- � SAN JOAQUIN LOCAs. HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466»-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7S -`d�P�. <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 Sari Joaquin <br /> . County Ordinance No. 1862 and the Rulesand.--Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION1 ' CENSUS TRACT 101 - 2- r7 <br /> Owner's Name ~ " ... c L . . .._. Phone e <br /> Address <br /> City ' ' <br /> Contractor's Name License # 1_..L"u Phone <br /> TYPE OF WORK (Check): NEW WELL '/ DEEPEN '/ RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION _ ~PUMP REPAIR 7 PUMP REPLACEMENT /7 <br /> Other !/-7 . . . . . . <br /> DISTANCE TO NEAREST: SEPTIC TANKO `j SEWER LINES PIT PRIVY <br /> SEWAGEjDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> I ustrial A- Cable Tool Dia. of Weld. Excavation <br /> omestie/private i "Drilled Dia of Well Casing <br /> Domestic/public Driven, Gidge of''-CaAng <br /> Irrigation s Graved. Pack Depth of Grout Seal r <br /> Cathodic Protection IRotary< Type of Grout <br /> Disposal I Other Other Information <br /> GeophysicalSurface Seal Installed By: <br /> PUMP INSTALLATION-. Contractor <br /> Type cf Pump .P. ;� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: . . . <br /> / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate <br /> 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 ona new we1l;� .I-will.fdr-nis3i the' San-Joaqui:n_.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 GROUTIN FINAL SPE IO N. y <br /> SIGNED <br /> TITLE <br /> W LOT PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: <br /> 5PION PHASE III FINAL INSPECT ON <br /> INSPECTION B AT r INSPECTION BY DATE <br /> Ae <br /> - E H 1426 v .Rev. 1-74 -- -- -- 1,/W� OV <br />