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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO$rOFFICE USE: 1601 E. Hazelton Ave. Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74- -3. to <br /> THIS PERMIT WIRES- 1 YEAR FROM DATE ISSUED .Date Issued <br /> �r3 - (Complete In Triplicate) <br /> Appljcation is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This ap.p3Ication 'is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of i.he Sara Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION LU � <br /> �-�*-� CENSUS TRACT OlO-Cca—off . <br /> Owner's Name <br /> Phone 34 r <br /> Address 2City <br /> Contractor's Name <br /> License #/61373 Phone3C <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /7 RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION REPAIR /`] PUMP REPLACEMENT w <br /> Other /% �} <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES E PIT PRIVY Iw <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFYCATIONS <br /> Industrial . <br /> Cable Tool Dia. of--Well-Excavation 3 ' <br /> Domestic/private Drilled Dia. of Well Casing --t <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotaryi ' <br /> Type hof Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> _ k r ' <br /> PUMP :INSTALLATION: w - Contractor s ,� <br /> Typ a of'Pump <br /> H.P. <br /> PUMP REPLACEMENT: PState Work Done Y /nbo <br /> � �►;� <br /> PUS;REPAIR: . - /7 'State Wark Done- <br /> ESIRUCTION OF WELL: Well Diameter } <br /> ., 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 furnisli�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 FORA GROUT INSPECTION^ <br /> PRIOR TO GROUT;NG AUR-A­F­I—KkL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE t <br /> R DEPARTMENT USE ONLY <br /> _PHASE I ,. ' - <br /> APPLICATION ACCEPTS BY �.. DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONw <br /> .�. PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ _ DATE Z 1,3-7�1.' <br /> ^E H 1426 Rev. 1-74 -. <br /> 1-74 2M <br />