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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH` OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. - <br /> Telephone : (209) 466-6781 p / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedJAN 1 6 1978 <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 o e San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name C.�CJ Phone l <br /> Address Al CC.r, City G�6 <br /> Contractor's Name License 4f Phoneme <br /> GA <br /> t� <br /> TYPE OF WORK (Check) : NEW WELL '/—/ DEEPEN %/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION "t-• PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL 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/public Driven Gauge of Casing <br /> Irrigation - Graved Pack -Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout. _ <br /> Disposal Other Other Information - <br /> Geophysical Surface Seal Installed By: __t5i <br /> PUMP INSTALLATION: Contractor f. <br /> Type of Pump H.P. j <br /> PUMP REPLACEMENT: / / State Work'Done <br /> . I <br /> PUMP .REPAIR: <br /> / / State Work Done � <br /> t <br /> r <br /> DESTRUCTION OF WELL: Well Dia}neter 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 iaell 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 GR UTING FINAL INSPECTION. <br /> SIGNED TITLE <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 INSP CTION P III/ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> Ile <br /> E H 1426 Rev. 1-74 1/7�2M i <br />