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(,Y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 ;*OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 __Zno <br /> THIS PERMIT WIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ij • (Complete In Triplicate) <br /> Applicatiori is"41ereby`made to the San Joaquin Local 11ealth Distract for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinauce-No%' 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> ...Owner's Name Phone <br /> Address City ' � �� <br /> Contractor's Namer 10 <br /> '- <br /> License fZ 23 2.3 Phone3_4 — <br /> { <br /> TYPE Off' WORK (Check) : NEW WELL -1-7 DEEPEN -/-7 RECONDITION /7 DESTRUCTION r7 <br /> .PUMP INSTALLATION / PUMP REPAIR —7 PUMP REPLACEMENT <br /> Other ,/,/ E <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> wSEWAGEjDISP05AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i PROPERTY ;LINE - PRIVATE DOMESTIC WELT,' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> -lndustrial.l 1. Cable Tool Dia, of Well Excavation-. R' <br /> Domestic/private I Drilled Dia. of Well Casing W <br /> Doznes'tic/public Driven Gauge of Casing CiIrrigation y Gravel Pack Depth of Grout Seal <br /> Cathodic Protection i Rotary t Type of Grout <br /> ' Disposal 's. a. / Other Other Information <br /> Geophysical- " <br /> Surface Seal Installed B <br /> 1" �A•. <br /> PUMP INSTAL.LATIONo Cont-ractor <br /> Type .of Pump -- �' H.P / <br /> PUMP REPLACEMENT: + ' /'�41-- Sta 'd6Work Done � <br /> 4 .z t � e'�YLa -�- <br /> k <br /> PUMPAIR: <br />! REP _/_7 Sta, a Work Done "` . <br /> .. <br /> DESTRUCTION OF ..WELL: Well Aiameter -� Approximate Depth <br /> Describe Material and Procedure <br /> I hereby .gree .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 ue to the-best .of my knowledge"and belief. I WILL CALL FOR A GROUT INSPECTION vr, <br /> PRIOR TO GROU A P N INSPECTIQ . <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY c. 13i4TE <br /> ADDITIONAL COMMENTS: t ,.' s . <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br />,INSPECTION BY DATE INSPECTION- BY DATE <br /> E H. 1426 r Rev. :1-74 <br />