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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _30 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _ -,744- <br /> (Complete <br /> ,74(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 O 3 l�a te>� a� CENSUS TRACT <br /> Owner's Name <br /> a1 le Phone <br /> Address06 City �701c l-c�- <br /> Contractor's Name License # / 72S'Phone �54i <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN -7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /-7 PUMP REPLACEMENT /'-,-7 <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 /> X Domestic/private Drilled Dia. of Well Casing AZ, <br /> Domestic/public Driven Gauge of Casing u1 <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: Contractor <br /> Type of Pump H.P. C <br /> PUMP REPLACEMENT: j State Work Done <br /> PUMP :REPAIR: /7 State Work Done _ <br /> ,SES TRUCTION 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 thembefore putting the• well in use.. The above <br /> information is true to the-best of-my knV <br /> edge an belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING AND A FINAL I ON. <br /> SIGNED2! TLE <br /> a" r <br /> W PLO PLAN ON RE1SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 9 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PUSCITI/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> �1 E H 1426 Rev. 1-74 1-74 2M <br />