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p, t, .' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> :FOFIO ICE USE: 1601 E. Hazelton Ave. , Stockton,� Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S. SS'9/0 <br /> THIS PERMIT EXPIRES I YEAR FROM ,DATE 'ISSUED. Date Issued <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 appiication .is made in compliance with-San Joaquin <br /> County Ordinance No. 1862. and the Rules and Regulations of the San Joeq in Local Aealth District. <br /> JOB ADDRESS/LOCATION " 0,0,0 'Sae 4e � ENSUS TRACT <br /> Owner's Name Phone <br /> A <br /> Address _ S'23 3 X/- 0114 e-1 �at.Pct �� „ ..,_ City ' ' <br /> Contractor's Name License V/ A� 7)gThone 3?s <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN '/-7 RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION -1W PUMP REPAIR -/7 PUMP REPLACEMENT f7 <br /> Other / / . . . . . <br /> r <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 .. i Cable Tool Dia. of Well Excavation G►` <br /> Domestic/private Drilled Dia, of Well Casing. , <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation . t Gravel Pack Depth of Grout :Seal s <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:: State Work Done' <br /> UE&TRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Material and Procedure <br /> Z 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 anew 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-o �kn dge a d belief. I WILL CALL FOR GROUT INSPECTION <br /> PRIOR TO O TING AND A FINAL E N <br /> SIGNED• ITLE <br /> W P T PLAN ON ERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS:: <br /> PHASE II GROUT INSPECTION ., PHAS III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> i E H 1426 Rev. 1-74 . r 4/75 .2M - <br />