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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k FOAiOFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> M <br /> APPLICATION FOR WILL CONSTRUCTION OR PUMP PERMIT Permit No. �.{�3p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued x: _77 <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 /> t JOB ADDRESS/LOCATION '� �ig <br /> o CENSUS TRACT <br /> Owner°s Name r Phone <br /> Address �'� �� City <br /> Contractor's NameZ� n License # Phone j <br /> TYPE OF WORK (Check): NEW WELL "/-7 j <br /> DEEPEN -/-7 RECONDITION /7 DESTRUCTION % <br /> PUMP INSTALLATION PUMP REPAIR /7 PUMP REPLACEMENT rf <br /> i <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 a <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing CA <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout' <br /> Disposal1 . Other Other Information <br /> t Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor -Ly-ge <br /> Type of PUMP . <br /> i PUMP REPLACEMENT: /State Work Done .lizr �C!E'�1n1✓�r.�Y' -' .. ._� <br /> PUMP !REPAIR; <br /> /7 State Work Done <br /> f ,DESTRUCTION_OF WELL: Well Diameter Approximate Depth <br /> -_� Describe Material and Procedure <br /> t <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 GROUTINE AND A FING INSPECTION. <br /> SIGNED .. TITLE <br /> DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE � 5° 7 <br /> i <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHASE._III4F;1WAL INSPECTION <br /> INSPECTION BY DATE INSPECTION. BY ItI&OPATE IS=71 <br /> E H 1426 Rev. 1-74- - 3-7A IM <br />