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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> 4 <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.. 7 S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued <br /> (Complete In. Triplicate) <br /> Application is hereby made to the Sart 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 Saar Joaquin Local Health District <br /> JOB ADDRESS/LOCATION / �. f-n '0A S TRACT <br /> � Owner's Name r <br /> CA JQ Phone ' <br /> Address.- <br /> city "- <br /> Contractor's <br /> ddress. City .Contractor's Name License V Phone , <br /> TYPE OF WORK (Check)*. NEW WELL '/_7 DEEPEN /7 RECONDITION /_7 DESTRUCTION /—f <br /> PUMP INSTALLATION/ / PUMP REPAIR- PUMP REPLACEMENT /7 <br /> Other ET <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY q <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 /> i Industrial Cable Tool Dia. of Well Excavation <br />` <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 Other Information- -{ <br /> Geophysical Surface Seal ..Installed 'B : <br /> PUMP INSTALLATION: Contractor. <br /> Type of Pump _ H.P. <br /> a <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR; I State Work Done; . a . �d <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 /> f WELL DRILLERS REPORT of the well and notify them before putting.the..well. in.use.... The above <br /> r information is true to-the.best.of my.knowled a belief. 1 WILL CALL FOR A ,GROUT INSPECTION <br /> PRIOR TO TING AND A FINAL IN <br /> SIGNEq Ls 1TLEp <br /> P PLAN ON RE RSE SIDE " <br /> FOR DEPARTMENT USE ONLY , <br /> PHASE I <br /> APPLICATION ACCEPTED BY G✓ /� - DATE 7 -1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II INAL INSPECTION <br /> INSPECTION BY DATE _ INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 r^ !x/75 2M <br />