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SAN JOAQUIN LOCAL HEALTH.DISTRICT �.sA <br /> FOF,OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 P <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7K�}° <br /> THIS <br /> PERMIT EXPIRES 1 YEAR FROM DATE"ISSUED <br /> Date Issued6 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for; <br /> n described. This application is made �QlPlianceermit t <br /> PPw3th San Joaquin <br /> and/or install the work herein P <br /> lations of th an Joaquin Local Health District. <br /> County Ordinance No. 1862 and the Rules andegu <br /> � Ii CENSUS TRACT " <br /> JOB ADDRESS/LOCATION O <br /> Phon44 e�`fJ <br /> Owner's Name <br /> +{7 City <br /> Address.;? / <br /> License �G�. Phone <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN "/-7 RECONDITION /-7 DESTRUCTION /? <br /> PUMP INSTALLATION " PUMP REPAIR / / PUMP REPLACEMENT IT <br /> Other 1 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ,G <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 <br /> Cable Tool Dia. of Well Excavation <br /> I <br /> Domestic/private Drilled Dia. of Well Casing <br /> # Domestic/public Driven Gauge of Casing <br /> IGravel-Pack �1 Depth of Grout Seal <br /> Irrigation <br /> Cathodic Protection Rotary" F Type of Grout <br /> Disposal Other ;_ Other Information <br /> - Surface Seal Installed B <br /> Geophysical <br /> PUMP---INSTALLATION:— Contractor <br /> _ <br /> Type� of Pump � <br /> PUMP CEMENT. State a Wo <br /> rk Done <br /> REPLACEMENT: <br /> /. / <br /> S <br /> PUMP .REPAIR: / / State Work Done <br /> ( DES-TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> y Describe Material and Procedure <br /> � 4 <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 i <br /> WELL DRILLERS REPORT of the well and notify them before pgtting the -well in use. The above. <br /> information is true to the, best of" my knowledge and belief., I WILL C' OR A GROUT INSPECTION <br /> PRIOR TO G OUTING A FINAL INSPECTION. <br /> i TITLE 1 <br /> SIGNED <br /> I1 W P T PLAN ON RE FRSE SID ) :r <br /> OR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE IN INSPECTION <br /> PHASE I GROUT INSPECTION INSPECTION BY TE <br /> ' INSPEC�BY DATE <br /> ! 3/76 2M <br /> E H 1426 Rdv. 1-74 <br />