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pUSESAN JOAQUIN LOCAL HEALTH DISTRICT c� <br /> Fos-,OFFICE : 1601 E. Hazelton Ave. , Stockton, Calif, b <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -)7 <br /> i <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued /0'Y�-7 <br /> (Complete In Triplicate} <br /> APpli-cition 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 <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address <br />` City <br /> Contractor's NameEZ <br /> / -. A� <br /> N '-�_ License #334-75,*12hone <br /> TYPE OF WORK (Check) : NEW WELL <br /> / DEEPEN /_/ RECONDITION /_/ DESTRUCTION !/-7- <br /> PUMP INSTALLATION ( PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / f <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PTT PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> THER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL-- <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of We11 Excavation <br /> Domestic/private DrilledDomestDia, of Well Casing <br /> Irrigation <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - <br /> H.P. ' <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL; Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 thewell in use.. . The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />?RIOR TO G TING AND INA INSPECTION, <br /> SIGNED <br /> TITLE <br /> (DRAW, PLOT PLAN ON REVERSE SIDE} <br /> PHASE I FOR DEPARTMENT USE ONLY <br />---- <br /> kPPLICATION ACCEPTED BY <br /> kDDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY PHASE III/FINAL INSPECTION <br /> DATE INSPECTION BY <br /> DATE <br /> E 4 1426 Rev. 11-74 N y <br />