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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ` <br /> Telephone : (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-6 77e ; <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 /> JOB ADDRESS/LOCATION / Z CENSUS TRACT <br /> Owner's Name Phone �/� - /7U3 <br /> Address 12YdZ- City <br /> Contractor's Name - License # Zo60 Phone . - Z <br /> TYPE OF WORK (Check) : NEW WWELL '/ DEEPEN ./_/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT I-T <br /> ` Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' PROPERTY LIME - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> t Industrial. Cable Tool Dia. of Well. Excavation <br /> li Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing l _ <br /> r Irrigation Gravel Pack Depth of Grout Seal ( — <br /> Cathodic Protection _ Rotary Type of Grout`- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By-:-.. <br /> PUMP INSTALLATION:: Contractor <br /> Type of Pump .-w. H.P. <br /> PUMP REPLACEMENT: / / State Work Done " 1 <br /> PUMP '.REPAIR: / / State Work Done ` <br /> DES-TRUCTION 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 />'E 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 TING ANDA VINAL SPECTION. <br /> SIGNED TITLE ,k. <br /> W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE o <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE III/F•INAL INSPECTION ' <br /> INSPECTION BY DATE- ZX -71 INSPECTION BY - DATE <br /> ,X77 2?"'N <br /> EH 1426 Rev. 1-74 ' <br />