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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 1 <br /> Telephone : (209) 466-6781 �1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No J/ -17/.s <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ��� <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 l7 Sj N T CENSUS TRACT <br /> Owner's Name C Phone 7-Q 62 <br /> Address St <br /> City 6scaaa, <br /> Contractor's Name / E „J License #,,279&& Phone <br /> TYPE OF WORK (Check) t._ NEW-;,-WEL-Ll/ / DEEPEN %/ RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / PUMP REPAIR /% PUMP REPLACEMENT <br /> Other ] f` <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-fCasing l �� <br /> Irrigation Gravel Pack Depth of Grout Seal `rU <br /> Cathodic Protection `Rotary Type--of---Grout" <br /> Disposal 1 Other Other Information_ <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump --j H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter (',( Approximate Depth <br /> Describe MateriallaVid Prifleduie <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 GRO ING AND A,,FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOY DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE lo2 4 T7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS4,XXI/FIN4 INSPECTI N <br /> AT <br /> INSPECTION BY DE INSPECTION B DATE 'Z 77 <br /> E H._1426 Rev. . 1-74 <br /> 2M K <br />