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SAN JOAQUIN LOCAL HEALTH. DISTRICT tkj ,- 1,5 <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � '7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7- <br /> 77- <br /> THIS <br /> 7fTHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued A-18'-2 <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 he described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1 th Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/ 0 Tv L'CNWTHAC T_,'7 <br /> Owner's N Phone <br /> Address / Ar7 City <br /> Contractor's Name �U �5 License /0 -373 Phonilbo <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/-7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR PUMP REPLACEMENT /7 <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 WELT, 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 Casin7 C7 <br /> g <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 H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: _ State Work Done <br /> DESS CTION 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 is true to the-beat o£ my..knowledge and belief. I WILL CALL FOR A GROUT I95PECTION,- <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. "�- <br /> SIGNED TITLE <br /> !(DRAW! (DRAWTof PLAN 'ON iaVftSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE A <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRO N TION PHA I INAL INSPECTIO <br /> INSPECTION BY TE "-'INSPECTION BY DATE <br /> 3y�6 moi;t <br /> E R 1426 Rev. 1. 74 .� y` <br /> - �-- < . <br />