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SAN JOAQUIN LOCAL HEALTH. DISTRICT - <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7]-//(S <br /> THIS PERMIT EXPIRES l YEAR FROM DATEISSUEDDate 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 San Joaquin i <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone 1 4 D " ,] )- 7 <br /> Address _ —_— 4/ City a f <br /> Contractor's Name ��Q,��C�L, License #1' 1373 Phone 3 <br /> 'i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN/ / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 /> Domestic private Drilled Dia. of Well Casing <br /> Domestic/public _Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection Rotary Type. of Grout � + <br /> Disposal. Other Other Information <br /> ._..Ge6physical_3_,_. _.-. _ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT: State Work Done , r <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION_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 i,q true to the best of- my nowledge and belief. I WILL CALL FOR A GROUT INSPECTIO <br /> PRIOR TO -GRO)_517INGIAND 4AAL INSPE ION. <br /> SIGNED TITLE <br /> W MT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIOR PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ' <br /> w <br /> E H 1426 Rev. 1-74 .. <br /> �, 3/76 2M <br />