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t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ,' OFFICE USE: `1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 11-1-77 <br /> 14 (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 anddt�he teles pd Regulations of the San Joaquin Local Health District. <br /> l v U � <br /> 17�0` n . <br /> k JOB ADDRESS/LOCATIO <br /> N USCT <br /> Owner's Name <br /> Phone fp <br /> Address , 6S----' <br /> City <br /> Contractor's <br /> ityContractor's Name � <br /> ` icense �� <br /> TYPE OF WORK (Check) : NEW L <br /> W L / / DEEPEN "/ / RECONDITION / - <br /> / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /% PUMP REPLACEMENT_ / / <br /> Other <br /> DISTANCETO NEAREST: -SEPTIC iANK 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 /> Industrial F Cable Tool Dia, of Well Excavation <br /> Domestic/private � <br /> /private Drilled Dia, of Well Casing \j <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation f Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal t Other Other Information <br /> Geophysical Surface Seal Installed B .: <br /> PUMP INSTALLATION: <br /> N. Contractor '�( ';/� > ,� <br /> Type of Pump - — -- H.P. <br /> PUMP REPLACEMENT: State Work Done 7e, .e <br /> PUMP .REPAIR: + <br /> / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with 'all laws and regulations of the San Joaquin Local Health District <br /> and the State of California .per--twining 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 i <br /> PRIOR TO UTING _ FIN.AL INSPECTION. <br /> SIGNED- <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) _ <br /> PHASE I &�- <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: I s <br /> PHASE II GROUT IN CTION PHA II/F NAL INSPEC IQ <br /> INSPECTION BY DATE INSPECTION BY DATE 1417 { <br /> 14 74 <br /> E H 1426 Rev. , 1-74 0,x%7 <br />