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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi OFFICE USE: V 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209)' 466-6781 <br /> .APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. W. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Aereby 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 /> i <br /> .TOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> i <br /> Address TO City <br /> Z&424UZ <br /> Contractor's Name License # ;t 4G2 Phone 21e, - <br /> 1 <br /> TYPE OF WORK (Check) : 'NEW WELL ff DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE, TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY'LINE -- PRIVATE DOMESTIC 'WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL •.. CONSTRUCTION SPECIFICATIONS . <br /> Industrial _JkC_ Cable.-Tool Dia, of Well--Excavation _ 41, <br /> Domestic/private Drilled Dia, of Well Casing -- .f <br /> Domestic/public ` _— <br /> /P � 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: Contractor <br /> Type of Pump H.P. <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 iwell ''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 thevwel.lkin use. ' The above <br /> information 's true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G NG JiND A AL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE ,S��S' 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA I/ NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7 7 <br /> E H 1426 Rev. 1-74 Z7 -2M <br />