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"� SAN JOAQUIN LOCAL HEALTH DISTRICT ¢ <br /> FO£x.OFFICE USE: ' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /a-/-7S- <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 � . CENSUS TRACT <br /> 42 za <br /> Owner's Name A Phone <br /> Address City , <br /> Contractor's Name - License # Phone <br /> TYPE OF WORK (Check): NEW WELL '/-7 DEEPEN /? RECONDITION /-7 DESTRUCTION f-7PUMP INSTALLATION . PUMP REPAIR1/ 7 PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES WIT 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/privateDrilled Dia. of Well Casing <br /> Domestic/public .._w_a-.. 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 ITIONS Contractor <br /> NS { <br /> Type .o£ Pump 61115 H.P. <br /> PUMP REPLACEMENT: . /-7 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 o,f 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 GROIWING AND h FIN INSPECTION. <br /> SIGNED X TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY a DATE l 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIVM4L INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 -_ 2m <br />