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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 160 . Hazelton Ave. , Stockton, Calms 6"V <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued//'/J'77 <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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /-p qn R CENSUS TRACT <br /> Owner's Name �d� Phone <br /> Address _ // Cit <br /> Contractor's Name /1��.-�. � , Cense jyg&7� Phoox"- U,7 <br /> TYPE OF WORK (Check) : NEW WELL /Z DEEPEN / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION UMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK .���1 f SEWER LINES _L/0 PIT PRIVY <br /> SEWAGE DISPOAS L 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 i rQ <br /> Domestic/public Driven Gauge of Casing II \n <br /> irigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection --rotary Type of Grout 4 $ (° - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: i? <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION 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 best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU D A FINAL INSPECTION <br /> SIGNED - TITLE � t � , <br /> (DRA�PLOT LAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY-�� jf) pO DATE r i -71 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION „ <br /> INSPECTION BY DATE INSPECTION BY DATE ., --_ ,J <br /> E H 1426 Rev. - I-74 6/77 _ 2M /' <br />