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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3 <br /> 1.0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /� - 77 <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 /> r County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Z <br /> CENSUS TRACT <br /> { Owner's Name Phorie 3 2 <br /> Address C111 (;(f_ <br /> City <br /> Contractor's Name License � '-- <br /> #1-- 23. Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPENT %/ RECONDITION / / DESTRUCTION /_ <br /> AL <br /> PUMP INSTLATION / / PUMP REPAIR 2d_ PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> t PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 0. <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public . Driven Gauge of Casing 4111 <br /> Irrigation a Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> --Disposal Other Other Information.: <br /> S � <br /> { Geophysical .1� <br /> Surface Seal Installed B : �\\ <br /> PUMP INSTALLATION: ContractorZz- <br /> J Type of Pump <br /> '-{-- =C H.P. <br /> C� <br /> PUMP REPLACEMENT: / / State Work Done " <br /> PUMP .REPAIR: State Work Done P A. <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 GRO N AND A F AL INSP CT ION. <br /> SIGNED TITLE ' <br /> DRAW 4LIOIT PLAN ON <br /> REVERSE SIDE)_ <br /> FOR DEPARTMENT USE ONLY <br /> If PHASE I �� _ �� 1 <br /> APPLICATION ACCEPTED BY -.X L.%�Q � DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE I NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY , DATE --.2 [S/„_7 <br /> E H 1426 Rev. 1-74 376 2M <br />