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; <br /> �c SAN JOAQUIN LOCAL'HEALTH DISTRICT <n <br /> F0 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> I ' <br /> Telephone : (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 2IS4 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued rz-��- 7 <br /> 4 i <br /> c (Complete In Triplicate) <br /> Application is hereby made to the 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. i <br /> JOB ADDRESS/LOCATION 2 s _. t <br /> _ F CENSUSr_/TRACT .�yf 9S <br /> Owner's Name l 7-S <br /> Phone } <br /> Address <br /> City sizodc <br /> Contractor's Name License # Phone ' <br /> _ a <br /> TYPE OF WORK (Check) : NEW WELL I`I DEEPEN / I RECONDITION / DESTRUCTION <br /> PUMP INSTALLATION X PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other Ll <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 I}OMESTIC WELL <br /> INTENDED USE <br /> Industrial TYPE OF WELL CONSTRUCTION SPECIFICATIONS I <br /> .!. <br /> Cable Tool Dia, of Well Excavation <br /> (AJDomestic/private Drilled Dia, of Well Casing p <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other ,.Other Information <br /> Geophysical <br /> - Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P•. 3 b . <br /> PUMP REPLACEMENT: / / State Work Done * <br /> PUMP .REPAIR: / / State Work Done <br /> E <br />)ES-TRUCTION OF WELL: Well Diameter r/ <br /> f Approximate Depth <br /> Describe Material and Procedure <br /> F <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local 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 <br /> SELL DRILLERS REPORT of the well and notify them before putting. the well in use. . The above C <br /> Information is true to the best my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTLNG N ION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br />'HASE I FOR DEPARTMENT USE ONLY <br /> TPLICATION ACCEPTED BY DATE � -77 <br /> ODITIONAL COMMENT$ _tA <br /> PHASE II GROUT INSPECTIO PHASFInITI/FI AL INSPECTION <br /> LNSPECTION BY DATE INSPECTION BY <br /> E H 1426 <br /> Rev. 1-74 6,/77 2M <br />