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'` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: N eol E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2,L?j&P <br /> 'THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued j- - g- <br /> y (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 � 0 � �,z..__0 Cif- CENSUS TRACT . <br /> Owner's Name Phone <br /> Address doo City - - <br /> Contractor's Name - License # Phone <br /> TYPE OF WORK (Check) : NEW WELL '/7 DEEPEN / / RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / —PUMP. REPAIR PUMP REPLACEMENT <br /> Other '/_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER . <br /> PROPERTY LINE - PRIVATE DOMESTICWELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation _TT <br /> Domestic/private Drilled Dia. of Well Casing <br /> ' Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout i <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> k PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done p <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED 1.4TITLE <br /> (DRAW POT PLAN ON REVERSE SIDE) - -- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ i . DATE /O,,Z-Z.eL <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 26 <br /> 4 3/76 2M <br /> E H 1426 Rev. '1-74 <br />