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( SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> SOF OVFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. S <br /> Telephone : (209) 466-61781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . 7.77 <br /> (Complete- In Triplicate) <br /> Application is 1. hereby made tothe 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 o-f . the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . ai / ✓I dJ'!� CENSUS TRACT F <br /> � . : Al Phone <br /> Owner's Name <br /> Address : . /� City <br /> Contractor's Name License-11 1 � 1 none -�fi�(, <br /> It a <br /> TYPE OF WORK (Check} ; NEW WELL / / DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION / J <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /? 1 <br /> Other i`/ / <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 J Cable Tool Dia. of Well Excavation 4 <br /> Domestic/private 1 Drilled Dia. of Well Casing \ <br /> Domestic/public. i Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> I Cathodic Protection Rotary 'Type of Grout <br /> Disposal ! Other Other Information <br /> Geophysical- Surface- Seal Installed By: <br /> PUMP INSTALLATION: Contracto <br /> Type of PumpF 1,crG4 H.P, - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP Rte: /X/ State Work Done yid -45 11 <br /> � <br /> DESTRUCTION OF WELL: Well :Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all Laws and regulations of the Saxe. Joaquin Local Health District <br /> and the State of California pertaining to or 'regulating well construction. Within FIFTEEN DAYS <br /> a"f:ter 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 true to the best of- my know dge an belief. I WILL CALL FOR A GROUT INSPECTION <br /> ' PRIOR TO GRO TING AN A FINAL ION. <br /> SIGNED TITLE <br /> f D L PLAN ON 'RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 5 <br /> APPLICATION ACCEPTED BY DATE f] <br /> w ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUTfINSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY r>DATE INSPECTION BY ➢ATE /r7 <br /> v�77 2M <br /> F u IA?A RA,._ . 1-74 - - - <br />