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SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 �� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .d 7 f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 77 <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 he described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT {� <br /> + �� d E <br /> Owner s Name Phone CY <br /> Address City <br /> Contractor's Name ' e� License # ,3 Phone ' - S <br /> i <br /> TYPE-OF WORK- (Check)-:-- =NEW--WE-L-L- /:/- -DEEPEN--/- -/­RECOND`ITTON°��/ DESTRUCTION-/? <br /> PUMP INSTALLATION / / PUMP REPAIR/, PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 Q'Q <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 .-- : 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 /> G <br /> XPUMPREPLACEMENT: <br /> : State Work Done `L(/ p <br /> PUMP .REPAIR: / State Work Done x <br /> k 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED - TITLE11;4 z <br /> w <br /> "(DIAW.PDOT PLAN ON REVERSE SIDE) 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE -/y'']7 _-- -- <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA /FI AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY ATE 7 <br /> r <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />