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SAN JOAQUIN LOCAL HEALTH DISTRICT L <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' �if) <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -lg77 <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/LOCATIONS � 1 <br /> `� 0 3 <br /> CENSUS TRACT �jSl-fl6-a3 <br /> f <br /> O <br /> Owner's Name , Phone <br /> Address , t <br /> City <br /> Contractor's Name License #-Z7 ¢ Phone�������� I <br /> i <br /> TYPE OF WORK (Check) : NEW WELL � DEEPEN /% RECONDITION /�/ DESTRUCTION /- <br /> PUMP INSTALLATION /—/ PUMP REPAIR/ / PUMP REPLACEMENT /-7 i <br /> Other <br /> DIST E TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> fV1,/ O �-` SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> �J PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able 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 /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> P.UMP_:REP ALR: -_.-- State-Work--Done -�- <br />)ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> L 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 ii <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Lnformation is rue to the best 9pf my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUT D A FINAL 29PEC710N. f <br />;IGNED <br /> TITLE i <br /> (DRAW PO LAN LON—REVERSE SIDE <br /> FO EPARTMENT USE ONLY <br />?RASE I <br /> LPPLICATION ACCEPTED BY DATE <br /> LDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION { <br />=NSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />