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SAN JOAQUIN LOO?�L HEALTH DISTRICT' <br /> FOR rOFFICE USE: 1601 E. Hazelton` Ave. , Stockton', Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2L-fTlz-' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 22_1Z--2&' <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 Joaquit <br /> t County Ordinance No. 1862 and the Rule and Reg 1 tions of q e San oaq in Local Health Districts <br /> l71 o S OL <br /> JOB ADDRESS/LOCATION SUS TRACT <br /> { <br /> Owner's Name <br /> Phone <br /> i o <br /> Address City <br /> Contractor's Name License # Phone x-76 d <br /> E y` <br /> TYPE'Oi?-WORKr{Check)`. NEW`WELL DEEPEN"/-t. RECO T 0/7, DESTRUCTION~f <br /> PUMP INSTALLATION / / PUMP REPAIR /7_PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _2a! SEWER LINES 7j PIT PRIVY <br /> SEWAGE DISPOSAL FIELD �,P- CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE---PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V <br /> Industrial Cable Tool' Dia. of Well Excavation G� <br /> Domestic/private Drilled i Dia. of Well Casing /&I/&. <br /> _ Domestic/public Driven I .� Gauge of Casing <br /> t Irrigation Gravel Pack Depth of Grout Seal <br /> 1 Cathodic Protection Rotary Type- of Grout <br /> r ca <br /> — <br /> Disposal Other `� Other,Information / <br /> Geophysical c 'Surface ,Seal Installed Bvi <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump `f H.P. <br /> PUMP REPLACEMENT: Y/ /T State_Work Done <br /> PUMP '.REPAIR _. / F -State-Work-Done <br /> E&TRUCTION OF WELL: Well Diameter Approximate TDepth <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 DisCrictta <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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASZ II UT INSPECTIO PHASE III/FINAL INSPECTION <br /> t INSPECTION BY DATEZ I INSPECTION BY DATE <br /> ��t E H 1426 Rev. 1-74 1-74 2M <br /> �. <br />