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Ise-.,SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 - <br /> APPLICATION <br /> 66-6781APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. )p <br /> THIS- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued l.- rZ <br /> (Complete In Triplicate) <br /> Application is Aereby made to the San Joaquin Local Health District for a permit to construct' <br /> and/or install the work herein described. This applicati is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rul and Re �l do the San Joaquin Local Health District. <br /> firs 5 <br /> JOB ADDRESS/LOCATI CENSUS TRACT ' <br /> VA <br /> Owner's Name -- `f Phone <br /> Address Ci <br /> Contractor's Name —�,, }} <br /> License =` �-3Phone`f' D� <br /> t, <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT / <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 v_ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary1 <br /> osa�l � Other Type Ype of Grout <br />--,—Disposal � <br /> P Other �Information { <br /> Geophysical i Surface Seal Installed BX: <br /> i <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: s <br /> State Work <br /> PUMP ,.REPAIR: / / State Work Done <br /> } <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED Q, TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) --- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ; <br /> APPLICATION ACCEPTED BYDAT /'7 - 77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-7A . 1/77 . _ 2M ' <br />