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SAN JOAQUIN LOCAL HEALTH- DISTRICT �. s <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. " <br /> Telephone: (209) ' 466-6781 U <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No <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 /> County Ordinance No: 1862 and the Rules and Regulations of the San Joaquin Local Health District. ., <br /> JOB ADDRESS/LOCATION SIIDiC/�� _ CENSUS TRACT <br /> Owner's Name ' �y�t� PhoneZ2-2- 0�3� <br /> Address City ] <br /> r . <br /> Contractor's Name License #Z hone <br /> L' <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTAL TION / / PUMP REPAIR/ / PUMP REPLACEMENT /� <br /> .Other---/._/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY,, <br /> SEWAGE DISPOSAL FIELD,, CESSPOOL/SEEPAGE PIT OTHER R <br /> ` PROPERTY LINE - PRIVATE DOMESTIC WELLZ.__Z! ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF_-WELL CONSTRUCTION SPECIFYATJONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> ti Domestic/private'YDrilled Dia. of Well Casing <br /> Domestic/public 'Driven Gauge of Casing Y <br /> Irrigations, R Gravel Pack Depth of Grout Seal f <br /> ;Cathodic Protection _ . otary Type of Grout <br /> .:Disposal Other Other Information <br /> `Ceophysi-cal _ _ Surface Seal Installed By_ <br /> PUMP INSTALLATION: ContractorT +. <br /> Type of Pump H.P. E <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ^ i <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> a <br /> I Hereby agree to comply with all laws and regulations of the San Joaquin Focal Health District 4 <br /> and the State of California pertaining to or regulating we11 ''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 thewell in use. The above <br /> information is true ,.to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION 4 <br /> PRIOR TO CROU A N SPECT ION. <br /> SIGNED d TITLE <br /> ( W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APFLICATION ACCEPTED BY F DATE <br /> ADDITIONAL COMMENTS: TV V <br /> PHASE II GWO S CTION PHASE TTI/FINAL INSPECTION <br /> INSPECTION BY DATEI INSPECTION BY DATE <br /> E H 1426 Rev. 1-74- Y � 7: ` 2M ! <br />