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SAN JOAQUIN LOCAL HEALTH DI TRICT <br /> FO l'ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. v <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,s-I,J <br /> ¢ 76-7si /0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued f 7Z6 <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 a Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> Owner's Name r/"`� r Phone 6 <br /> ,�, /7 <br /> Address <br /> Contractor's Name Licensee Phon bb�� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/DEEPEN / / RECONDITION /? DESTRUCTION /? - <br /> PUMP INSTALLATION /tom' PUMP REPAIR / / PUMP REPLACEMENT /-T <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/ EGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI S <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 1/Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: ' <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-beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION i <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 7777 TITLE <br /> D W._Pffif PLAN 'ON UTER E SIDE <br /> PHASE I FOR DEP TMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PRASE II ROUT INSPECTION PHAS I I/FINAL INSPECTIO <br /> INSPECTION BY � ATE J4 -�R- Z INSPECTION BY DATE <br /> EH12 3/76 � <br /> 4 6 Bev. 1-74 <br />