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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOVOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3Dj <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued �s-�' <br /> Application is hereby made to the San <br /> (Complete <br /> Triplicate) <br /> 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 3 Q /C� CENSUS TRACT <br /> Ow'ner's Name Phone <br /> Address <br /> City <br /> Contractor's Namee <br /> -C -- License ��hone �'3l 021'7 <br /> TYPE OF WORK (Check) : NEW WELL / J DEEPEN/_/ RECONDITION / / DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /77 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS K.Industrial Cable Tool Dia., of Well Excavation <br /> Domestic/private Drilled +' . Dia.. of Well Casing 0� <br /> Domestic/public Driven Gauge of Casing q <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 `INSTALLATION. Contractor j <br /> Type of Pump I H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> } <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br />�--Q- .� Approximate Depth' _ <br /> Describe Material and Procedure <br /> 2 <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 knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GR O NG AN IN INS I <br /> SIGNED TITLE j <br /> (D PLO LAN ON REVERSE SID j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r DATE / —/S 7 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA I/ _NAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION DATE -717 <br /> E H 1426 Rev. 1-74 1177 2M <br />