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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORIOFFICE USE: 1601 E. Hazelton Ave. Stockton Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�/-:300L/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6-12-'�7 <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 IVCENSUS TRACT <br /> r <br /> Owner r s NamePhone ?1 L �/� <br /> a <br /> Address SIM City <br /> Contractor°s Name e � �� ` _---- r- License # Phone <br /> TYPE OF WORK (Check): NEW WELLmx DEEPEN/-7 RECONDITION 1-T DESTRUCTION /-f <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES PIT PRIVY <br /> AL <br /> SEWAGE DISPOSELD 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 /> Domesticlprivate Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing - cgg - <br /> �� Irrigation Gravel Pack Depth of Grout Seal $f <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal m Other Other Information <br /> Geophysical Surface Seal. Installed By: Lhe e3e-6a=la <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j—/ State Work Done <br /> PUMP '.REPAIR: /7 State Work Done _ <br /> t <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth a , <br /> Describe Material and Procedure <br /> I herebya <br /> g ree 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 FORmA GROUT INSPECTION <br /> PRIOR TO GROUTING ANR A FINAL INSPECTION. <br /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE ���2 a1L <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IKIFINAL INSPECTION_ , <br /> INSPECTION BY DATE INSPECTION BY TE ' <br /> E H 1426 Rev. 1-74 3-74 <br />