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SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> 0-COFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: -(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '77„-(ZZ1,W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> l (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 /> i <br /> ,s <br /> Owner's Name u Phone <br /> Address - !'rl H _ City '69C A40,::� f <br /> Contractora Name Ta r,�t,ltd,,4 c License #o2790/UPhone=:,,�, 07 <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN /_7 RECONDITION /7 DESTRUCTION (7 <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMP REPLACEMENT / <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 E <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.)' y. Other. Other Information <br /> Geophysical Surface Seal Installed By_ I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> P!M :REPAIR: / / -State Work Done <br /> ,SES TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with. all laws and regulations of the Sari 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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A KN INSPECTION. � <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE)- <br /> -A FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT WSPECTION PHAS I N INSPECT N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> IE H 1426 Rev. 1-74 1-74 2M <br />