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I <br /> Gd �_,•��olo � J SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL O 'FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. t4S10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (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 /> Countyf Ordinance No. 1862 and the Rules and Regulations of the San •Josquin Local Health District. <br /> JOB ADDRESS/LOCATION y CENSUS TRACT ' <br /> Owner's Name .f Phone <br /> Address o Cito4l e, <br /> y <br /> _ .. <br /> Contractor's Name = <br /> � License # ?�hona <br /> TYPE OF WORK (Check) : NEW WELL/? DEEPEN -/7 RECONDITION /7 DESTRUCTION /_ <br /> PUMP INSTALLATION/ _/ PUMP REPAIR/? PUMP REPLACEMENT / <br /> Other E7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> G SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER s <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 Ca . <br /> Domestic/public 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 'B : <br /> PUMP INSTALLATION: a - f <br /> Contractor x - <br /> i Type° of Pump H.P. <br /> f <br /> PUMP REPLACEMENT: . State Work Done " ^' <br /> PUMP ,REPAIR: /% State'.Work Done <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 befoke putting.the..welk in .use.... The above <br /> information is true to- the-best my.. o edge d belief. I WILL CALL FOR A ,GROUT INSPECTION <br />( PRIOR TO G OUTINGAND A F N, <br /> SIGNED NS, <br /> - <br /> RAW PLOT PLAN ON VERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATED S� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN9PECTION PHASE III FINAL INSPECTION <br />/ INSPECTION BY DATE INSPECTION BY DATE <br /> E H\1,426 Rev. 1-74' -S� '"'� -` ' h/75 2H �'. <br />