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SAN JOAQUIN LOCAL 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. 7 �� <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 Z2 /"-�CENSUS TRACT <br /> Owner's Name Phone 171Z r-o <br /> Address f 3 - J-,/- / � ll / City �0�,r!! N <br /> Contractor's Name License 73Phone,26K96` � <br /> TYPE OF WORK (Check) : NEW WELL J7 DEEPEN -/-T RECONDITION /7 DESTRUCTION 17 <br /> PUMP INSTALLATION J / PUMP REPAIR /7 PUMP REPLACEMENT <br /> Other ET <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 �1 <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 /> Geophysical Surface Seal. Installed By: <br /> PUMP INSTALLATION. Contractor <br /> Type of Pumpj� H.P. <br /> PUMP REPLACEMENT: _ State Work44 <br /> PUMP .REPAIR: State Work ne <br /> DESTRUCTION OF WELL: Well Diameter J` ©' � S��7—' 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 is true to the-best-of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROJgING AND A F AL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMEFT USE ONLY <br /> PHASE I 1 <br /> APPLICATION ACCEPTED BY //L�L,i��" DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSP CTION PHASE III FINAL INSPECTIJDN <br /> INSPECTION BY DATE INSPECTION BY DATE p /� <br /> E H 1426 Rev. 1-74 h/75 2M <br />