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SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton. Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 77'1750 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued '0y'71,7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin .Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made incompliance with San JoaquiW <br /> County Ordinance No... 1862 and .the Rules. and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone 07<e��' ' f <br /> Address City S7 c `�`i! <br /> Contractor's Name 1 v c, License #26eS7kPhone <br /> - OA� <br /> TYPE OF WORK (Check) : NEWWELI / DEEPEN / / RECONDITION / f DESTRUCTION /-7 obi <br /> PUMP INSTALLATION /G�- PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other f / <br /> 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK _Z07j`-(SEWER LINES/&v PIT PRIVY <br /> SEWAGE DISPOSAL FIELD �j CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE , TYPE OF WELL 'CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Diam- of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing _ <br /> Domestic/public Driven Gaiige of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of-Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: ContractorC <br /> Type of Pump H.P. <br /> PUMP- REPLACEMENT: / / State Work Done <br /> 3— <br /> PUMP .REPAIR: / 7M State Work Done <br /> IDES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I herebyagree to comply with all laws and regulations of the San Joaquin Local Health District <br /> g P y g <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completiion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> I� WELL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <br /> information is true fo the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND'_ FINAL INSPECTION. <br /> SIGNEDTITLE_ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1 <br /> APPLICATION ACCEPTED BY DATE�� r' _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR SP TION PHASE III/FINAL INSPECTION <br /> INSPECTION BY 6ATE INSPECTION BY D E <br /> 1M <br /> F H 1426 Rau- . 1-74 <br />