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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Teleptiozie : (209) 466-61781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1. YEAR FROM - <br /> DATE .ISSUED Date Issued .. <br /> (Complete In Triplicate ) <br /> A licat on is hereby made to the San Joaquin Local health District far a permit to construct <br /> PP <br /> and/or install the work hereescribc This application is made in compliance with San Joaquin: <br /> County Ordinance No. 1862 d les nd Regulations of the San Joaquin Local Health District. <br /> JOB A 3-/-LOCATION "5 �+4/f�U'��"I�ENSUS TRACT - f <br /> Owner r s Name � Phone <br /> Address -. City <br /> � G <br /> Contractor's Name <br /> License Phone <br /> { <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN RECONDITION / / DESTRUCTION /-7 Q <br /> PUMP INSTLATION J}Q PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> L�CLVV <br /> Other <br />'[_PISTANCE TO NEAREST: SEPTIC TANK:r0 -t--SEWER LINES ,"-PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CES POOL/SEEPAGE PIC> BOTHER 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 Gaugeof Casing "! <br /> - Irrigation Gravel Pack Depth of Grout Seal �� <br /> Cathodic Protection Rotary Type hof Grout <br /> Disposal Other Other' Informationw <br /> Geophysical Surface Seal Installed B __ <br /> PUMP INSTALLATION: Contractor <br /> TYPe of Fump H.P. <br /> PUMP REPLACEMENT: / / State Work Done 1 ° <br /> a <br /> PUMP REPAIR: / / State Work Done <br /> Approximate De'nth <br /> DESTRUCTION OF WELL: Well Diameter ` PP p <br /> Describe Mater iaroure <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 Iwell "construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San .Joaquan 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 INSPECTI:O.N ar - <br /> SIGNED <br /> (D P LOT -MAIr ON REVERSE SIDE) <br /> - FOR DEP MENTlUSE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY- DATE r 7 <br /> f ADDITIONAL COMMENTS: ¢ <br /> + PHAS I G UT INSPEC I N P I/ NAL INSPECTION <br /> ' INSPECTION BY DATE INSPECTION BY DATE <br /> 2M <br /> L E.1-I 1426 Rev. - I-74 <br />