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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF,,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. / <br /> Telephone: (209) 466-6781 v <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuea 1978 <br /> (Complete In -Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct I <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 Joauin Local Health District. <br /> JOB ADDRESS/LOCA "1 ' 7 4E• CENSUS TRACT <br /> Owner's Name Phone / Y!� <br /> Address / z�jCity <br /> Contractor's Name �� /// License ������ Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /_/ DESTRUCTION <br /> AL <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 /> 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* <br /> PUMP INSTALLATION.: Contractorcv� <br /> Type of Pump Tf.P• / <br /> PUMP REPLACEMENT: / / State Work Done ��0 d <br /> PUMP .REPAIR: / / State Work Done <br /> I 'DES•TRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> t Describe Material and Procedure <br /> F <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 GRO TING AN IN AL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE I- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT ONPHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY' DATE <br /> pF"77 M <br /> Y.' U 1 A 7 C. 13-E 1-..7.. <br />