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L . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. ; <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 7-// <br /> l� <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issuedg� <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe San Joaquin Local Health District for a permit to construct <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 ccthe San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name IF Phone3CP <br /> Address _ .� i-�-� City 6 - <br /> Contractor's Name 4.1. License #A� Phone3 <br /> i' <br /> } <br /> TYPE OF WORK (Check) : NEW WELL '/ DEEPEN — <br /> RECONDITION /� DESTRUCTION <br /> AL <br /> PUMP INSTALLATION / / PUMP REPAIR � PUMP REPLACEMENT /7 j <br /> Other Y-7 , <br /> DISTANCE TO NEAREST: SEPTIC'TANK SEWER LINES PIT PRIVY ` <br /> SEWAGEiDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL '' PUBLIC DOMESTIC WELL (Al <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial.. _ _ xl __... ._Cable Tool Dia., of Well Excavation. y <br /> Domestic/private I Drilled Dia. of Well Casing Q <br /> Domestic/public it Driven Gauge of Casing <br /> Irrigation Ii Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I1 Rotary Type of Grout 4 <br /> Disposal I Other Other Information <br /> Geophysical. _. u. . _ _. _ Surface_.S.eal Installed By: _ <br /> LJ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ! L� <br /> PUMP REPLACEMENT:, I State Work Done <br /> .: } r n <br /> PUMP .REPAIR: State Work DoneIt <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i l <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District i <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 ;sell and notify them before putting the -well in use. The above <br /> information is true to the best of my. owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G D A I INSPECT N. <br /> SIGNED TITLE <br /> W PL TPLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I p r� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT 'INSPEC ION a PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 - - - <br />