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eSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0__R OFFICE USE.: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-� <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 wank herein. described. This. appXication is :Wade 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 fZ (r -CENSUS TRACT <br /> Owner I s Name . Phone ,- <br /> Address <br /> hone ,Address <br /> LhGI�~ city - <br /> Contractor's <br /> ity -Contractor's Name " L License # Phone ,,5- _ , <br /> ltJ <br /> s ,5>- SCJ <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/? RECONDITION % f DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/-7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 1 W <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 By: <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 <br /> Approximate Depth _ <br /> Describe Material and Procedure <br /> . . r <br /> I hereby agree tocomplywith4all 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 .af my-knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GR TING 'AND AL INSP ION <br /> SIGNED / ITLE <br /> (DRAW P T PLAN ON REV E SIDE <br /> FOR DEPARTMENT E ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE. / 7� <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY. DATE <br /> E H 1426 Rev. 1-74 i` 1./7 C� om <br />