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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE"OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - 7-7 <br /> t i (Complete In Triplicate) <br /> Application is hereby made tojthe San Joaquin Local Health District for a permit to construct i <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/LOC TION- � r� o CENSUS TRACT I <br /> Owner's Name �x Phone <br /> Address City 'def W,4 � <br /> Contractor's Name a, License # 7(1,pz Phone Y- 7 <br /> TYPE OF WORK (Check) : NEW WELL 'AL7 DEEPEN -/-7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT/7 <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 WELT. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 11 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 R i <br /> Cathodic Protection _ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: --. Contractor- <br /> Type <br /> ContractorType .of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP !REPAIR: -/? State Work Done <br /> t <br /> ;RES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> I and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after comp leti of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLER <br /> SAE of the well and notify them before putting the.-well in use.. The above <br /> informatiop fiss. <br /> e to the blest of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TolghwNiAWAND A FI INSPECTION. <br /> SIGNEDt TITLE - <br /> t (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE 'ONLY <br />� <br /> PHASE I ' <br /> ZOO APPLICATION ACCEPTED BY ✓ � f - - - -- _.__ DATE f� <br /> ADDITIONAL COMMENTS:, - -` <br /> PHASE II GROUT INSPECTION PHASE UI INSPECTION <br /> INSPECTION BY DATE T77 INSPECTION BY _ DATE <br /> 1 , E H 1426 Rev. 1-74 <br /> 1-74 2M <br />