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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE-'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?S- <br /> 77-g9-4 I° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3� -V <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 CENSUS TRACT <br /> Owner's Name �f Phone 3 tle r a f <br /> Address L f City <br /> Contractor's Name �� . 1��6�� icenses' Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /ZT—DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / UNP REPAIR/ / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK a SEWER LINES J_ PIT -PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 4--'Ca-ble Tool Dia. of Well Excavation f <br /> 4---Domestic/private Drilled Dia. of Well Casing N.? - <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout _ l C�' <br /> Disposal Other Other Information <br /> Geophysical L Surface Seal Installed B <br /> �A <br /> PUMP INSTALLATION: Contractor >r� <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROY2ING,4D A FINAL INSPECT_ZOIJo <br /> SIGNED TITLE _ <br /> ill(bRAW- PLOT PLAN 'ON REVERSE SIDE)- <br /> FOR DEPARTMENT USE ONLY dI <br /> PHASE I <br /> APPLICATION ACCEPTED BY v✓ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 3/76 2M <br />. Asa.. - -�- -- -- - -- --�-- <br />