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L <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> fo rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S"` 79 ;} <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-",2. - 7 <br /> S- <br /> (Complete In Triplicate) <br /> ®27-170-7- <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�1,®CATION 1 (J CENSUS TRACT <br /> Owner's Name Phone 3 4 ,? 114 <br /> Address f l )/ City <br /> Contractor's Name <br /> License # x-3)3 Phone3 <br /> TYPE OF WORK (Check): NEW WELL -L-7 DEEPEN/ 7 RECONDITION /-7 DESTRUCTION /7_ <br /> PUMP INSTALLATION jE/ PUMP REPAIR ,O. PUMP REPLACEMENT 1]� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY -} <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �' J <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 of`Casing t <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information y <br /> Geophysical Surface Seal Installed By ! <br /> PUMP INSTALLATION: Contractor k9, <br /> Type of Pump H.P. % C] <br /> PUMP REPLACEMENT: / / State Work Done <br /> i <br />--PULP-'.REPAIR:_ - - - - -J �State Work Done . , - <br /> ... I <br /> ESTRUCTION 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 <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 true to the•best.af my .knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR AND NAL INSPECTION. <br /> SIGNED TITLE <br /> PA,(DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPT USEONLY - -_.- <br /> PHASE I <br /> APPLICATION ACCEPTED BY S . DATE <br /> ADDITIONAL CONMNTS <br /> PHASE II GROUT INSPECTION P SE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ., - DATE -a-©'? <br /> 'k <br /> 1 E H 1426 Rev. 1-74 1-74 ?M ; <br />