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SAN JO Q 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. 76-;2-v 84l <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> 11 r <br /> . � <br /> JOB ADDRESS/LOCATION S �so�3 <br /> r CENSUS TRACT �7 <br /> Owner's Name Phone ? - <br /> Address 9C� City t2zutgew <br /> Contractor's Name f License # AZ&Z- Phone <br /> TYPE OF WORK (Check)s NEW WELL ',.YDEEPEN /7 RECONDITION /? DESTRUCTION 1-j .: <br /> Other INSTALLATION J / PUMP REPAIR"/� PUMP REPLACEMENT 1_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER h <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. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ✓_ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection __✓- Rotary Type of Grout <br /> Disposal Other Geophysical Other Information <br /> ...�`_. <br /> Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ..REPAIR: /7 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 /> 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 FOR A 'GROUT INSPECTION <br /> PRIOR TO G UTING AND F AL INS CTIO <br /> SIGNED ITLE <br /> DRA LOT P ON REV E SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION' ACCEPTED BY DATE 7 �� <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHAS I FIN INSPECTION <br /> INSPECTION BY _. DATE INSPECTION BY DATE - <br /> E H 1426 Rev. 1-74 �" 4175 <br />