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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORiOFF E USE: ,1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � ] <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued`y <br /> (Complete in Triplicate) <br /> APPlicition is hereby made to the San Joaquin Local Health District for a permit <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquiti construct <br /> and/or install the work herein described. This application is made in compSa <br /> liance with" Joaquin` <br /> n Local lIealth District, <br /> JOB ADDRESS/LOCATION ��� C�✓ � <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> a1 <br /> Address" <br /> �- city , <br /> Contractor's Name r .� �' r"" <br /> License # ��-Phone' �� <br /> TYPE OF WORK (Check): NEW WELL '/? DEEPEN /�--RECONDITION /� DESTRUCT <br /> PUMP INSTALLATION ION �/� F <br /> - / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other Z77 <br /> .,meq , <br /> DISTANCE TO NEAREST: SEPTIC TANK 1" <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPQSAL FIRLDCt— <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL�SEEPAPGUBLIC DOMESTIC WELL E PIT OTHER <br /> INTENDED USE, WELL <br /> $ TYPE OF WELL CONSTRUCTION SPECIFICATIONS. <br /> Industrial Cable Tool Dia. of Well Excavation <br /> DosticJprivate Drilled i, - <br /> -Domestic/public Dia. of Casing <br /> Driven Gaugeof Casing <br /> J. Irrigation �`� L .s � Gravel Pack Depth 'of Groin Seal - <br /> Cathodic Protecltion Rotary Type of Grout <br /> � Disposal � `w:�.�.. Other <br /> Geophysical ------.—_ Other Information <br /> Surface Seal Installed S : <br /> PUMP INSTALLATION: Contractor <br /> Tppe' o'f Pump42 <br /> F H.P. S i <br /> PUMP REPLACEMENT: /_ State Work Donee 7 <br /> PUMP '.REPAIR: /?-,.State Work `Dane <br /> ESTRUCTION OF WELL; Well Diameter w <br /> —' <br /> ¢ Describe Material and Procedure Approximate Depth <br /> <r <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 know edg and Lief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO G G ANDA FIN INSPECTIO <br /> SIGNED <br /> TYLE �'� <br /> 0 PLAN ON R . RST SID <br /> PHASE I R DEPARTMENT USE ONLY <br /> iyPLICATION ACCEPTED BY <br /> kDDITIONAL COMMENTS: DATE <br /> PHASE II. GROUT INSPECTION <br /> CNSPECTION BYPHASE III INAL INSPECTION <br /> DATE INSPECTION HY DATE <br /> E_H 1426 Rev. 1-74 � <br /> f , ,,. �„ <br />