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X76-gal 6D ' <br /> SAN JOAQUIN .LOCAL HEALTH DISTRICT ,r 76 <br /> _70F::,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. w.. <br /> Telephone: (209) 466-6781 T <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -3- e <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 a.pplica'tion is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rule and 7ations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address 4 City' <br /> Contractor's Name .. License Phone ' <br /> TYPE OF WORK (Check): NEW WELL t7 DEEPEN '/�f�_R GONDZTION,,,f- , „DESTRUCTION <br /> __ _ " € <br /> `""PUMP-INSf LATION--/_I PUMP. REPAIR /-7 PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGETP-ITS OTHER <br /> PROPERTY LINE -- f DOMESTIC. WELL r PUBLIC DOMESTIC WELL <br /> INTENDED,_USE TYPE- OF WELL CONSTRUCTION SPECIFICATIPMS <br /> Industri 1 Cable Tool, Diai of Well Excavation <br /> Domestic/private k Drilled Dia. of Well Casing <br /> - <br /> DomEeitic/public i Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout-Sea-1— C� <br /> Cathodic Protection l :i Rotary _Type of_ Grout <br /> Disposal 1 Other ° Other Information. <br /> Geophysical , Surface Seal Installed By <br /> PUMP INSTALLATION; Contractor,. <br /> Type ,of Pump - H.P. "N,.. <br /> PUMP REPLACEMENT: . / / state Work'SDone�% L <br /> PUMP ,REPAIR: /_7 State Work Done . . . . <br /> DESTRUCTION OF WELL: WelliDiameter �r Approximate Depth �� <br /> D scribe Mat tial and Procedure <br /> I hereby agree to comply with d1l laws and re&latio-w of the San'd aquin Local Health District. ' <br />'-and the State of California:,per.taining 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.-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR iNG 'AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1,- <br /> 4 APPLICATION ACCEPTED BY DATE6 <br /> 4 ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT•INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION' BY DATE INSPECTION BY DATE <br /> " --E..H_ 1426 Rev. 1-74 <" r. 511!W I <br />