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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , . Stockton, Calif. lJ <br /> .a Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 7-11 <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 Jo4quin , <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. 3 <br /> JOB ADDRESS/LOCATION /f CENSUS TRACT i <br /> Owner's Name Phone <br /> Address7/ Cityd �fL(� <br /> Contractor's Name License # Phone <br /> t <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION /_7 DESTRUCTION T7 ' <br /> PUMP INSTALLATION LX/ 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 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 F~ <br /> Domestic/public" Driven Gauge of Casing <br /> Irrigation .. 'Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ,''Rotary Type of Grout <br /> Deposal _ '` Other Other Information <br /> Geophysical ' Surface Seal Installed By: <br /> PUMP INSTALLATION:, Contractor– (� <br /> Type -of Pump H.P. .�. <br /> PUMP REPLAC NT: T/ State Work Done z <br /> _ E r �[ 4V�� <br /> PUMP . R: %C/ State Work Done .. <br /> DESTRUCTION OF WELL: Well Diameters_ '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 rm;d notify them before putting the well in use The above <br /> information is true to the best o nowle geai- belief. 1 WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G T NG AND A FIN <br /> SIGNED ITLE 'j' _ <br /> __=DRAW)PtNdY PLAN ON REVERSE SIDE) . <br /> OR DEPARTMENT USE ONLY i <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ��i <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE X.JZIF.ANAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY yam--- DATE 77 <br /> 1177 . 2M <br /> E H 1426 Rev. 1-74 � — <br />