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Ca� o/o 414 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (249) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7V- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued T _- ,? <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 S$3 N so/a r', G�.cr�c„[ �1,� CENSUS TRACT <br /> Owner's Name ,��- /F�a k Phone <br /> Address 3 V N City 5040 Adm <br /> Contractor's Name / R License # S y 3,1---Phone Gam-W 74 <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN -/—/ RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATIONT/ PUMP REPAIR 1_1 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 W <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ,K 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 6 H.P. / <br /> PUMP /77 State Work Done <br /> PUMP '.REPAIR: /7 State Work Done <br /> ES•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 San Joaquin Local Health District 1 <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 G NG AND A FINAL INSPECTIO <br /> SIGNED TLE P- <br /> DRA P PLAN ON REV SE SIDE <br /> Loor <br /> 1?6R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE FIN INSPECTIO 1 <br /> INSPECTION BY DATE INSPECTION- BY DATE 7 <br /> 4 E H 1426 Rev. 1-74 1-74 2M <br />