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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi;OFFICE USE: 1601_ E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit'No. 7� <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued4N3 ` <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 /> CENSUS TRACT ' <br /> Owner's Name <br /> Phone ' <br /> Address 49 S' <br /> qq . city <br /> Contractor's Name <br /> J. License ` Phone <br /> TYPE{ OF WORK (Check): NEW WELL /-7 DEEPEN -/-7 RECONDITION f7 DESTRUCTION /-7 <br /> PUMP INSTALLATION'/-/ PUMP REPAIR 17 PUMP REPLACEMENT- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWHR-LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD "V •.CESSPOOL/SEEPAGE PIT OTHER 9L-) <br /> PROPERTY LINE -- PRIVATE STIC WELL PUBLIC DOMESTIC WELL C <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 /> 10 Domestic/public DrivenGauge of Casing <br /> f� Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> IIhDisposal Other Other,-Information <br /> liGeophysical. _ _ Surface Seal Installed "By: .- <br /> PUMP I�INSTALLATIONs Contractor <br /> Type of Pump .. <br /> PUMP -i.EPLACEMENT: State Work Doh Y <br /> ��! _-.,�• _ 1. i <br /> PUMP 'f REPAIR: <br /> / I State Work Done <br /> DESSTRIVCTION OF WELL: Well,Diameter <br /> Approximate Depth Y <br /> Describe. Material and Procedure,:, <br /> i <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 wo-rk on a:-new well, I will' furnish the San ,Joaquin Local Health District a I <br /> li <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe-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 />------------- <br /> PRIORM[TO GROUTING 'AND FINAL INSPECTION. ` <br /> SIGNED <br /> TITLE4-&- - , w* <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> ?FOR DEeMI T USE ONLY <br /> PHASE111I <br /> APPMATION' ACCEPTED BY A DATE 1 <br /> ADDITIONAL COMMENTS: 2 <br /> �i PHASE II GROUT INSPECTION PHASE III XINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> 1 <br /> f <br /> E ji 1426 Rev. 1-74 _-- <br /> ' t��9� 9M } <br />