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SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> FOF 0 ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ; Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74 <br /> f-� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z'�j ? <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 Joaquin <br />.County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> �Q CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address 73 C�tr-r city <br /> Contractor's Name License # 3 73.4one <br /> _ <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN/_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / f PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY y <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 <br /> Domestic/public Driven Gauge of Casing <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 <br /> • H.P. r� <br />'UMP REPLACEMENT: / / State Work Done <br /> App"M.: State Work Done <br />►ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distract <br /> ind 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 /> FELL DRILLERS REPORT of the well and notify them before putting the .well in use. The above <br />.nformation is true to the best of nowledge.--acrd elief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTING AND A FINAL INSPEC 0 <br />'IGNED ITLE ���►� <br /> RA LO PLAN ON R SE SIDE) '! <br /> FOR DEPARTMENT USE ONLY <br /> RASE I <br /> PPLICATION ACCEPTED BY DATE ��! <br /> DDITIONAL COMMENTS: <br /> Z2 <br /> PHASE II GROUT NSPECTION P I/ INAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE 7 <br /> E H 1426 Rev. 1-74 1727 2M <br />