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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> s FOR OFFICE USE: /11Z� 1_601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781_ <br /> k APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED <br /> ' Date Issued 2iG-_?z <br /> .(Complete InTriplicate) <br /> Application is hereby made �to the San Joaquin, Local Health District fora permit to construct <br /> County <br /> Ordinance <br /> work .herein described. This application is made in compliance with San Joa uir <br /> ' County Ordinance No. .1862 and the Rules and Regulations of the San Joaquin. Local Health District. <br /> f <br /> .FOB ADDRESS/LOCATION <br /> k CENSUS TRACT <br /> Owner's Name , <br /> Phone <br /> Address J <br /> ' City <br /> Contractor's Name <br /> License,111 A Phon ' <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN %/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR <br /> Other / / T / Pte' REPLACEMENT /-7 <br />� f <br /> DISTANCE TO NEAREST: SEPTICITANK , SEWER LINES �� <br /> f SEWAGE:?DISPOSAL FIELD PIT PRIVY <br /> C SSPOOL/SEEPAGE PIT OTHER <br /> f PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF-WELL Q, <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation i <br /> Domestic/private Drilled <br /> Domestic/publicDia, of Well Casing <br /> Driven Gauge of Casin >r <br /> Irrigation ;! Gravel Pack g <br /> Cathodic Protection i Rotary Depth of Grout Seal. �- r <br /> Disposal Type of Grout <br /> �# Other Other Information <br /> Geophysical I Surface Seal Installed B : <br /> PUMP INSTALLATION: . <br /> Contractor <br /> Type of Pump <br /> 10H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: E1 <br /> State Work Done <br /> DECTION OF WELL: Well Diameter <br /> Describre Material and Procedure Approximate Depth <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 k <br /> WELL DRILLERS REPORT of the well and notify thein 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 <br /> 111 :11111' '11111 111$ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE �-- <br /> PHASE I <br /> $ FOR DEPARTMENT. .USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: �� DATEj- 7B <br /> P E II G OUT IIVSPE ION <br /> INSPECTION BY PHASE III/FINAL INSPECTION <br /> DATE 7 INSPECTION BY DATE <br /> E H 1426 Rev— 1-74 1-74 ii/77 *� <br />