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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 3.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 10 <br /> 77- og'Ia <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 San Joaquin <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 -f ��f <br /> Address / City ' jam' <br /> Contractor's Name License # IQ hone Q� <br /> TYPE OF WORK (Check) : NEW WELL /�'� DEEPEN '/-7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION 'tet= PUMP REPAIR/-7—PUMP REPLACEMENT /r 7 <br /> Other %// <br /> DISTANCE TO NEAREST: SEPTIC TANK /dam 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 Peak 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: <br /> Contractor <br /> Type of Pump H.P. 1 <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / 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- iell. 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 GROUTING AND A FINAL INSPECTION. 1 <br /> SIGNED TITLE �/1 + <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPAEMET USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAU i I AL INSFBCTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> I <br /> E H 1426 Rev. 1-74 r` h/75 2.M I <br />