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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOTO OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. / <br /> Telephone: (209) 466-6781 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7_ zaj <br /> ale THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �`' 2 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 in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> tS�/LOCATIOXj, <br /> iJO ADDRE <br /> 24A-%,.>w„n d+ �f CENSUS TRACT <br /> Owner's Name Phone 3 W __5 X'? <br /> Address Q City T p� <br /> Contractor's Name License V6.2i 73 Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL ,_�f DEEPEN/_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR [/ PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK .rf-f 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 Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: 1} _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: State Work Done <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 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 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR IN AND A FI AL INS ECTION. <br /> SIGNED TITLE � ,� •�� � ,��,` I: ,, <br /> W PL T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -77 <br /> E H 1426 Rev. 1-74 . <br /> 3/76 2M <br />