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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. J 7,a <br /> ,14 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaqui3 <br /> + County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / / CENSUS TRACT <br /> Owner's Name /t.G Phone <br /> ' <br /> Address - / City _ <br /> ( ® <br /> I.k Contractor's Name Ze5 License Phone 9"q;a-, <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /%f <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 /> IndustrialCable Tool Dia. of Well Excavation <br /> Domestic/private -`.. ,Drilled Dia. of Well Casing <br /> t Domestic/public a Driven Gauge of Casing 0 <br /> Irrigation 3. -,_Gravel ;Pack Depth of Grout Seal <br /> Cathodic Protection. Rotary Type of Grout <br /> Disposal Other Other Information <br /> .Surface Seal- Ins-Called B <br /> a ' a�/L <br /> PUMP INSTALLATION: Contactor <br /> �Nx <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / .` State Work Don r <br /> PUMP .REPAIR: / / 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 /> C 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, <br /> well and notify them before putting the well in use. The above <br /> information' is true to thebest of- my knowledge and belief. I WILL C FOR A GROUT INSPECTION <br /> PRIOR TOG UTING _ININSPJ%CTION. <br /> SIGNED ' TITLE <br /> D WPI, T' PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /a <br /> ADDITIONAL COMMENTS: I <br /> I PHASE I GROUTIINSPECTION PHASE FINAL INSPECTION <br /> i INSPECTION BY tDATE INSPECTION BY � ATE z <br /> E H 1426 Rev. 1-74 l = 3/76 2M <br />