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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ,*OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) -466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 y �9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED Date Issued/,/ <br /> (Complete In Triplicate) <br /> Applicaition is hereby made to the San Joaquin Local Health Disttict for a permit to construct <br /> and/or install the work herein described. This application is trade in compliance with San'-Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of .jhe San Joaquin Local Health District. <br /> f JOB ADDRES /LOCATION i CJ N N a CENSUS TRACT <br /> Owner's Name Phone <br /> Address _ �J <br /> r City <br /> ' 'f/ Lc7^� p� - __ License 1� Phone <br /> contractor's Name .� <br /> 44 <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN '/-T RECONDITION /-T DESTRUCTION /-7PUMP INSTALLATION /—/ —PUMP PUMP REPAIR —PUMP REPLACEMENT �T <br /> AL <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER .LINES RIT PRIVY <br /> EWA E SI'SPOSAL FIELD _ CESSPOOL/S EPAGE 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. ofWell Casing <br /> Domestic/publics 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 ,.''Y Surface. Seal Installed BY: <br /> � yr' <br /> PUMP INSTALLATION: Contractor �l # <br /> Type of Pump R.P. <br /> PUMP REPLACEMENT: Ll State Work Done <br /> PUN��REPAIR:5: - --State Work hone <br /> PES®RUCTION OF WELL: Well Diameter j; Approximate Depth <br /> Describe Material and Procedure i <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 FORA GROUT INSPECTION <br /> PRIOR TO GRN TING AND AL INSPECTION. <br /> r SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> A�� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �` 7 <br /> ADDITIONAL' COPMENTS: <br /> PHASE II- GROUT PHA E II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY f- DATE 3 <br /> 4 ;~R H 1426 Rev. 1-74 1-74 2M <br />