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SAN JOAQ <br /> UIN LOCAL HEALTH DISTRICT <br /> a�' <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. tz <br /> Telephone: (209) 466-6781PO <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7? <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 Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/ @N Ir r CENSUS TRACT <br /> Owner's Name /�(' <<<7 Phone <br /> Address City <br /> t _ <br /> Contractor's Name ) (� /"!?��l �Z S l /� t - `i License <br /> t <br /> TYPE OF WORK (Check) : NEW WELL X 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 0\ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation �/7_11, <br /> _ Domestic/private Drilled Dia. of Well Casing A SAS C <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal -''c7 <br /> Cathodic Protection _ X _ Rotary Type of Groutir9T�2 0` <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: // S <br /> PUMP INSTALLATION: Contractor T V�C7���(s /��'l!�'v <br /> Type of Pump �-u. H.P. '21 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / 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 GROUTING AND A FINAL INSPECTIO <br /> SIGNED <br /> W PLOT ON REVERSE SIDE <br /> FOR DIEPARTMENT USE ONLY <br /> PHASE I �J DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE 30-71 INSPECTION BY DATE " <br /> 1777 214 <br /> E H 1426 Rev. 1-74 <br />