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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' <br /> FOR CE_ i�E: 1601 E. Hazelton Ave, , S•tockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued- 9-�7'7d <br /> (Complete In Triplicate) <br /> Application is Aereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work her described. This application is made in compliance with San Joaquin <br /> County�Ordinance, No_,.�.-1.862 and the Rules and Regulations of he San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CILT3 TRACT <br /> Owner's Name Phone G <br /> Address <br /> city+�� <br /> Contractbr's Name .License #a�flj�Z Phone <br /> F i � <br /> TYPE OF WORK-"'(Che.ck)—NEW WELT, `/ - DEEPEN /_/ RECONDITION '/—/ DESTRUCTION /_7PUMP INSTM.TION` / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK X50`}-SEWER LINES} PIT PRIVY <br /> SEWAGE DISPOSAL FIELD —, CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINgW VRIVATE DOMESTIC WELL 4D�4" 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 r _I_;_ <br /> Irrigation Gravel Pack Depth of Grout Seal �p r _ U <br /> Cathodic ProtectionRotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> �x <br /> PUMP .REPAIR: _ / / State Work Done - <br /> PIES•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 we11 •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 y <br /> information is true to the bes o knowledge and belief. I WILL CALL FOR A GROUT INSPECTION . <br />'RIOR TO OUTING D A F A N ION. , ;, + <br /> SIGNED TITLE <br /> �. (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> kPPLICATION ACCEPTED BY 1 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> r <br /> E H 1426 Rasr_ t_�t � `Ti�/Q'h, I/77 .?M <br />