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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ./�a�-7 7 <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 incompliance with San Joaquin ji <br /> i.County Ordinance No. 1862 and the Rul and Regulations of the San Joaquin Local Health District. <br /> !! CENSUS TRACT <br /> JOB ADDRESS/LOCATION ! 5 .i d <br /> Owner's Name <br /> !� Phone <br /> Gam] i City <br /> Address <br /> Contractor's Name License � E►SA Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN %/ RECONDITION_/ / DESTRUCTION f� <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other,.:[/—/ <br /> I?TSTANCETO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> I4 SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �U <br /> Industrial f Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation ;1 Gravel Pack Depth of Groin Seal <br /> Cathodic Protection l Rotary Type of Gout z <br /> Disposal Other Other Information ' <br /> Geophysical - Surface Seal. Installed By:___ <br /> F . <br />! PUMP INSTALLATION: Contractor <br /> Typeof Pump <br /> PUMP REPLACEMENT: (State Work Done <br /> PUMP .REPAIR: / / .State Work Done <br /> *J-' A roximate Depth <br /> DESTRUCTION OF WELL: Wella.°Diameter pp p <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 them before putting the -well in use. The above <br /> information is true to the best of- my knowledge and belief. I WILL C OR A GROUT INSPECTION <br /> PRIOR TO G OUTING A INAL INSP CT N. <br /> SIGNED TITLE <br /> (DRAW PL T� PLAN ON REVERSE S DE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY Y '\ <br /> ADDITIONAL COMMENTS: <br /> PHASE ROUTlINSPECTION PHASE I/FIN INSPECTION <br /> INSPECTION BY tDATE INSPECTION BY DATV <br /> -7 <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />