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SAN JOAQUIN LOCAL HEALTH DISTRICT �� <br /> FOE OFFICE USE: e9f, hull-601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209), 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> T7 78 9l�' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-- ?-2 <br /> ,;Z <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 3�,E CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> t <br /> Contractor's Nameyew,"?5 -eV �19W �.�/'"' License <br /> i <br /> TYPE OF WORK (Check) : NEW WELL XT DEEPEN/ / RECONDITION_/ / DESTRUCTION /-7 <br /> PUMP INSTATION PUMP REPAIR / / PUMP REPLACEMENT /? <br /> EiLL <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK +SEWER LINES j- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT�_�J�,l *- OTHER <br /> PROPERTY LIN -JPRIVATE DOMESTIC WELL`Q�#PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool Dia. of Well Excavation '- R <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 Grouts/j�lt/� <br /> Disposal 7 Other Other Information <br /> Geophysical Surface Seal Installed B <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 knowled e and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED E S <br /> (DRA PLOT&PYM ON REVERSE SIDE) 1 <br /> FOR DE ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIA/g4NAL INSPECTION <br /> INSPECTION BY �`J -7� DATE INSPECTION BY DATE d 2 <br /> E H 1426 Rev. 1-74 ��.. ._ 1/77 <br />