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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> TOT'-OFFICE USE: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .77-Lap <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued r <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 Re u1 tions of the San Joaquin Local Health.District. <br /> JOB ADDRESS/LOCATION 3�I CENSUS TRACT mi <br /> Owner's Name Phone <br /> F <br /> Address City <br /> Contractor's Name License #D P(o ',?dPhone �3- <br /> TYPE OF WORK (Chezk) : NEW WELL t/? DEEPEN /7 RECONDITION / DESTRUCTION f7 r <br /> PUMP IkSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPUSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC.WELL PUBLIC DOMESTIC WE L ' <br /> INTENDED -USE _ - .TYPE-OF WELL- CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well. Excavation <br /> Domestic/privateDrilled Dia. of Well Casing <br /> Domestic/public _ Driven. Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> g _ <br /> Cathodic Protection " Rotary Type of Grout _ <br /> Disposal Other Other Information_ <br />\ Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. '" 2 <br /> PULP REPLACEMENT: . AV Stat e Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-tRUCTION OF WELL: Well Diameter Approximate Depth "44 <br /> Describe Material and Procedure <br /> • h <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 FIFTEIN 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 myknowledge and belief. 1 WILL CALL FOR A GROUT INSPECTI�1, <br /> PRIOR TO G OUTING AQ A FINAIr I1jSPWL0N. <br />! SIGNED TITLE <br /> D W. PLAN 'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> NPECTION AL INSPECTION . <br /> II GRb I <br /> INSPECTION BY DATE INSPECTION BY �� <br /> k 3176 z� <br /> E H 1426 Rev. '1. 74 r <br />