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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'EO-.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. -J_A <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 -"--377 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 9 75r <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 -r-r> CENSUS TRACT i <br /> Owner's NamePhone <br /> Address City <br /> Contractor's Name License # _4d;�Phone <br /> TYPE OF WORK (Check): NEW WELL I� DEEPEN /? RECONDITION /7 DESTRUCTION %j <br /> PUMP INST LATION / / PUMP REPAIR •/_7 PUMP REPLACEMENT /7 <br /> -Other / / <br /> DISTANCE TO NEAREST:. SEPTIC TANK L6 . SEWER LINES PIT PRIVY <br /> SEWAGE-DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 0 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 Seal <br /> Cathodic Protection Rotary. Type of Grout <br /> Disposal - Other Other Information' <br /> Geophysical / Surface Seal Installed By: ,_-___ s. <br /> PUMP INSTALLATION: Contractor / <br /> 'hype 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 /> y 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"constr_uction. 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 w. <br /> information is true to the. best of- my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR OUT G AND PECTION. <br /> SIGNS \ TITLE ti <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I /L <br /> ,F�OREPAJRTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 9 y _7s <br /> ADDITIONAL COMMENTS: <br /> PHASE JZ G INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION $Y `11 TE INSPECTION BY DATE <br /> E H 1426 Rev. 1--74 r` !:/75 2M <br />