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Y J/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7F-0TZFFICE 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 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 /> 1 L'1 All .[Irf--%Tl.��i�y cENsu3 TRACT <br /> JOB ADDRESS/LOCATION <br /> Owner's Name 4 ,✓. 'F / Ml's >r//w/�C - Phone <br /> Address City -, <br /> Contractor's Name d License 2 Phonefj,/ <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /7 RECONDITION /-7 DESTRUCTION /—T <br /> PUMP INSTALLATION/�gUMP REPAIR-1-7-PUMP REPLACEMENT /7 <br /> Other I / <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 L--Cable• Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 40 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> . <br /> w <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 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 GWTING AND A FINAL INSPECT <br /> ION. <br /> SIGNED TITLE ' t <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI PHAS I FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> E H 1426 Rev. 1-74 __--- h/75 2M <br />