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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. <br /> 1 JAH 16 1976 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED r Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe San Joaquin Local Joaquin Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San <br /> County Ordinance No. 1862 and Rules and egulations of th an Joaquin Local Health District. 1 <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's Name <br /> { !� <br /> Address 077 City (yam <br /> t Contractor's Name �� <br /> - License #1;29e " Phone <br /> i <br /> i <br /> ' TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / , RECONDITION / / DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT <br /> kT <br /> I 4 Other <br /> IDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protections Rotary Type_of. Grout, ,__ <br /> Other Information <br /> —Disposal/-- y 1 Other ,;y_ . <br /> -- Surface"Seal"Installed B "" <br /> Geophysical--""'""` � <br /> i s <br /> ( PUMP INSTALLATION: Contractora/ H.P. <br /> Type of Pump <br /> IE <br /> REPLACEMENT State Work Done <br /> PUMP <br /> ' <br /> PUMP .REPAIR• / / State Work Done tQ�' <br /> IDES;TRUCTION Ok WELL: Well. Diameter <br /> Approximate Depth <br /> Describe Material and -Procedure <br /> I <br /> II hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> sand the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, - 1 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 TING AND AL INSPECTION. TITLE _ �� c --- <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE 71 SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE J <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: + PHASE IITfFINAL INSPECTION <br /> PHASE II GROUT: INSP CTTON DATE — <br /> INSPECTION BY DATE INSPECTION BY <br /> R 1177 <br />