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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE ,USE: i fi13 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2g_Tja,2Gr) <br /> THIS PERMIT EXPIRES. 1 YEAR FROM DATE ISSUED Date Issued �g" <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 /> County Ordinance No. 1862 'and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a CENSUS TRACT <br /> Owner's Name Phone <br /> Address iV City. <br /> Contractor's Name -Q.( �� Ph�one3_ <br /> _ LicenSe� = .. s <br /> h <br /> TYPE OF WORK (Check) : NEW WELL A;;? DEEPEN '/ / RECONDITION /7 DESTRUCTION / <br /> PUMP INSTALLATION '/ / PUMP REPAIR% /< PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES -'PIT PRIVY _ ' <br /> SEWAGE DISPOSAL FIELD1 CESSPOOL/SEEPAGE`PIT b OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL, _ PUBLIC DOMESTIC WELL <br /> ' INTENDED USE TYPE OF WELL "CONSTRUCTION SPECIFICATIONS \ <br /> Industrialable Tool ;Dia:� of Well Excavation Q <br /> mestic/private Drilled Dia.' of Well. Casing <br /> Domestic/public Driven Gauge of Casing ° <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection;. Rotary Type of Grout i !v <br /> Disposal Other Other Information.' <br /> Geophysical ' Surface Seal Installed By: ; \� <br /> Al <br /> PUMP INSTALLATION: Contractor P1 L40M ` <br /> Type of Pump H.P. _ -- <br /> 1 A <br /> PUMP REPLACEMENT,. State Work Done <br /> PUMP .REPAIR: j / State Work Done 1. <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 /> 4 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 rue to the best ofinmy knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU I D k,FTNAL IAWCTIO.. <br /> SIGNED jr TITLE <br /> DRAW.: ?j LAN 'ON -R-EVERSE SIDE <br /> FO DEPARTMENT USE ONLY d ! � <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 10Loioc. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE,,,IU/FINA INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />