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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR_ OFFICE USE: 1601 E. Hazelton Ave. , Stockton., Calif. <br /> Telephone : (204) 466--678 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. 7-4 '7f <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 Z� le 7e- -of074V CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> City <br /> Contractor's Name License bf,�0,7/ Phone)%o <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION_/ / DESTRUCTION <br /> PUMP INST LATION XPUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANVtrp t- SEWER LINES 74-p_ PIT PRIVY ---- <br /> SEWAGE DISPOSAL Y�IELD CESSPOOL/SEEPAGE PIT/" ETHER �- <br /> PROPERTY LINgi4°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 X Drilled Dia. .of Well Casing <br /> Domestic/public. �� Driven Gauge of Casing �. <br /> Irrigation Gravel Pack Depth of Grout Seal or-OV.-4— <br /> Cathodic <br /> Cathodic Protection Rotary Type of Grout j <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ �` H.P. <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 'constructi.on. 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 INSPECTION. <br /> SIGNED ITLE <br /> L P ON REVERSE SIDE) <br /> FOR DE ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ADDITIONAL COMMENTS: T' <br /> P 11 GROUT INSP I PHASE I/F NAL INSPECTIO <br /> INSPECTION BY )e DATE INSPECTION BY DATE d 7d <br /> E H 1426 Rev. - 1-74 - 2M <br />