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y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _FOR:ffICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> G, Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75--.2 39&-1 <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 app!ication is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the Sats Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION - CENSUS TRACT <br /> Owner's Nance Phone --7576 <br /> i <br />,AddressCity � <br /> / t <br /> Contractor's Nama License # Phone 5-7�-�� ( � # <br /> TYPE OF WORK (Check): NEW WELL ---'DEEPEN 17 RECONDITION /� DESTRUCTION % j <br /> PUMP INSTALLATION / / PUMP REPAIR'/-7 PUMP REPLACEMENT /7 4; <br /> s Other <br /> = ,. <br /> i <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES PIT PRIVY i <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 /> V Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 12 <br /> Irrigation Gravel Pack Depth of Grout Seal / <br /> Cathodic Protection ✓ Rotary Type of Grout <br /> Disposal Other Other Informations h —h, <br /> Geophysical Surface Seal Installed B <br />-PUMP INSTALLATION., Contractor . . . <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> Stats Work Done <br /> PUMP 'REPAIR: State Work Done E <br /> DESiTRUCTION ,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 e <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 QIROUTING - <br /> a . iNAI. I PE CT 0 . <br /> SIGNED % TITLE <br /> (DW PLOT PLAN ON RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APP ATION ACCEPTED BY DATE 45� ^2V <br /> ADDITIONAL COMMENTS: <br /> ' PHASINSPECTION -- PHAS I INSPECTION <br /> =INSPECTION BY TE INSPECTION BY DATE <br />