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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FNPUFFICE`'USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit-No. 7g, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued b=� <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 <br /> Address - --7 V -- City i <br /> i <br /> Contractor's Name License # A290355 Phone "5229022 <br /> TYPE OF WORK (Check) . NEW WELL/� DEEPEN / / RECONDITION /� DESTRUCTION / <br /> PUMP.iI STALLATI N- I- -P I ^REPAIR / I�� PUMP REP�ACEMENT�../ To- -< 1� <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 '' <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 Stanislaus Pump& Machinery Corporation ! <br /> Type of-Pump Johnston H•P „1b0 - j <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Desc"ribe"Material—and Procedure <br /> I hereby agree to cannply 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 knowle a and elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO INSPECTION. <br /> , <br /> SIGNED TITLE - ! <br /> DkAW:P-T PLAN''ON RE MSE SI <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I <br /> APPLICATION ACCEPTED BY DATE b " Z <br /> ADDITIONAL COMMENTS: <br />' PHASE II GROUT INSPECTION. :i. PHASE.III%FINAL INSPEC N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 e-� <br />