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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71/r2ir <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / -/J <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 z ,�,� ._ CENSUS TRACT <br /> Owner's Name ' Phone fj <br /> Address ( r C7 City • <br /> Contractor's Name License #A, .237-3 Phone 34 L22K <br /> TYPE OF WORK (Check} ; NEW WELL DEEPEN--/—/-/ RECONDITION /_/ DESTRUCTIONS' ' <br /> _ _ <br /> PUMP INSTALLATION/ / PUMP REPAIR/ J PUMP REPLACEMENT /-7 <br /> Other / / -- <br /> J <br /> DISTANCE TO NEAREST: SEPTIC TANK g6 *' SEWER LINES 4Q PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> f INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled- of We'll Casing 6 �� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> 'Cathodic Protections Rotary Type of Grout <br /> DisposalOther Other Information <br /> Geophysical Surface Seal Installed By: e <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump, H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: <br /> / / 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 Joagixin 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 4 <br /> PRIOR TO GRO NG AND A AL INSP CTION. <br /> SIGNED o <br /> TITLE <br /> W <br /> POT <br /> O PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �.12 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE ,V^ l lf17 <br /> E H 1426 Rev. 1-74 376 2M <br />