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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: V 601. E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7L--W3� <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 /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name7f Phone <?8 g <br /> Address' rr7 City 6SCA4Dter/ <br /> Contractor's Name , �/� W License 07 Phone <br /> k <br /> + I. <br /> TYPE OF4WORK (Check): NEW WELL /7 DEEPEN '/? RECONDITION /'7 DESTRUCTION /_7 <br /> '' - PUMP INSTALLATION /� PUMP REPAIR /� PUMP PLACEMENT <br /> Other- �. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SE9PAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL;' . TM 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/publich. Driven. Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal... - Nj <br /> Cathodic4Protection Rotary Type of Grout — y <br /> Disposal u..j Other Other In€ormation., •Oa <br /> Geophysical Surface Seal Installed BX: <br /> PUMP INSTALLATION: Contractor <br /> Typeof Pump- _ _ H.P. <br /> PUMP REPLACEMENT; .�, x � <br /> / State Work_tDone .. j <br /> PUP'S-'.REPAIR: ­" -_ L7- State Work Done _ <br /> E&TRUCTION 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 I <br /> information is true to the-best of my knowledge and belief., I WILL CALL OR A 'GROUT INSPECTION <br /> PRIOR TO GRD �INGND AFINAL�ISP�E�CTION. - <br /> SIGNED TITLE <br /> t <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE"ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C.,X# DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE lI GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY O DATE - cr <br /> F. , <br /> E H`1426 Rev. 1-74 <br />