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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FaPsOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue#M 3 - 1978 <br /> k <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 /> 3 414g <br /> JOB ADDRESS/LOCATION <br /> --- CENSUS TRACT <br /> :1 O�1 AE f/1/v C 1 v b <br /> Owner's Na Phone ' <br /> r <br /> Address D ' City ' <br /> Contractora Name Licens-/T',2--C�Phone7 <br /> TYPE 'OF WORK (Check)-. NEW-WELL / PEN ''/7 RECONDITION /F DESTRUCTION f <br /> PUMP' INSTALLATZON '/ UMP ,REPAIR'/� PUMP REPLACEMENT <br /> f .�..� .�. . . ..-.Other-/ <br /> DISTANCE TO NEAREST: SEPTIC TANK Q 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 /> mastic/private Drilled Dia. of Well Casing <br /> Domestic/public _.Driven :Gauge of Casing / <br /> Irrigation A.—Gravel Pack —Depth of Grout Seal <br /> Cathodic Protection / Rotary V Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br />` PUMP INSTALLATION: Contractor ch <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work -Done <br /> PUMP '.REPAIR: / / State'Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procd:dure <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 io or' regulaiing well-construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will ftirnish 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..,o£ my.-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR-'TO GROUTING AND A FIE& INSPECTION. <br /> SIGNED . ,. TITLE <br /> (DRAW PLOT PLAN ON REVERSE- SIDE) <br /> FOR'DEPARTMENT USE ONLY <br /> PI'I SR ;I j <br /> AFt•`'LICATION. ACCEPTED BY DATE ,3y) C r �� <br /> ' ADDITIONAL COMMENTS: <br /> ` PHASE II GROUT INSPECTION PHASE III FINAL INSPECT N <br /> § INSPECTION BY DATE INSPECTION BY DATE <br /> h/75 2M <br />