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/ SAN`JOAQUIN LOCAL HEALTH DISTRICT " <br /> FOk OFFICE USE: _, 1601 E. Hazelton Ave. Stockton Cali _ <br /> Telephone: (209) 466-6781 G�{,/� <br /> S APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7' ���� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 77 <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 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/LOCATION S l o �/ [ CENSUS TRACT <br /> Owner's Name Phone /_7 <br /> r 0 I4 2-� U - Cit N <br /> AddressP Y <br /> Contractor's Name CV (G fLicense # Phone ' <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /* <br /> PUMP INSTALLATION / / —,PUMP REPAIR / / 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 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 Driven Gauge of Casing <br /> Irrigation Gravel Pack x f Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: / / State Work Done <br /> pES•TRUCTION OF WELL: Well Diameter (L' "� 7f Approximate Depthp <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Locay 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the. well in use. The above <br /> information is tru o the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR T A FINAL INSPECTION. <br /> SIGNED <br /> D LOT PLAN ON REVERSE SIDE) <br /> F R ,DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY / 4'Y DATE�,; ///�- /V'7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II G U SP N P SF /FINAL INSP CTI N <br /> INSPECTION BY DAT VINSPECTION BXjV <br /> L <br /> E H 1426 Rev. 1-74 1777 2M <br />