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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: K/1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. J7 3 3 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued ,x-77 <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 x �( � CENSUS TRACT <br /> Owner's blame Z � Phone " Q� <br /> • <br /> Address ��e�. J ity <br /> C <br /> Contractor's Name License <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <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 Cable Tool Dia. of Well Excavation <br /> � lei Domestic/private Drilled Dia. of Well Casing <br /> Dornestic/public Driven Gauge of Casing �( <br /> Irrigation Gravel Pack Depth of Grout Seal q <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 CX H.P. <br /> PUMP REPLACEMENT: State Work Dane <br /> PUMP .REPAIR: / / . State Work Done <br /> DESS CTION 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 near 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 k wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND FINAL INSPECTI <br /> SIGNED TITLE <br /> D T PLAN ON RE t --VERSE SIDE) `'' ° " <br /> iFOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G SP CTION P -NAI.'INSPECTION <br /> INSPECTION BY IX DATE INSPECTION BY DATE <br /> E H 1.426 Rev. 1-74 3/76 2M <br />