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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calm ' <br /> IF Telephone : (209) 466-6781 '22-9,01W <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.Z_�-&5:3- �2 <br /> J <br /> _J71 (1jp THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued'- _J 7 <br /> (Complete In Triplicate) <br /> Applation is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work,i�herein described. This application is made in compliance with San Joaquin <br /> LCounty-Ordinance No. 18(-2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> I <br /> JOB ADDRESS/LOCATION , , I CENSUS TRACT <br />-Owner's NameAG Phone <br /> Address dM <br /> City <br /> Contractor's Name i License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_/ DESTRUCTION /`7 <br /> P[1MPINSTALLATION PUMP REPAIR <br /> Other / / PUMP-REPLACEMENT /� <br /> — — <br /> DISTANCE TO NEAREST: SEPTIC TANK 41_� SEWER LINES ��.,Q PIT PRIVY <br /> S&GE DISP S0 AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE 45�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 ,,� iDriven Gauge of Casing <br /> Irrigation , ; Grave, Pack Depth of Grout Seal <br /> Cathodic- Protection Rotary,�T Type of Grout r-= <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor r <br /> T}pe of Pump H.P. <br /> PUMP REPLACEMENT: /07 State Work Done <br /> PUMP .REPAIR: K <br /> /'I�/ State VorklD`one <br /> i <br /> i <br /> uESTRUCTION OF WELL: Wi011 Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to complylIwith 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 tte best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING, A ;:INAL INSPECTION, <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . . DATE 3" ��- :Z7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASEIII/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z <br /> E H 1426 Rev. 1-74 11 77. . 2M ? <br />