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y SAN JOAQUIN LOCAL HEALTH DISTRICT _. ... <br /> FOS;OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone; (209) 466-6781 f <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 r s and Regulations of; rhe San Joaquin Local. Health District. <br /> �1 � �ti <br /> JOB ADDRESS/LOCATI N f �� d �� `'' CENSUS TRACT <br /> Owner's Name �- XM/ Phone h��73� <br /> r <br /> Address ,� � � /�� City <br /> Contractor's Name License/ 7-37 <br /> TYPE QF WORK .(Check): NEW WELL -/? DEEPEN/7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /? PUMP REPLACEMENT / <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 WEL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled -Dia. of Well Casing o <br /> Domestic/public 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 By: - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: .,State Work Done <br /> i <br /> PUMP 'Stade Werk Doris, <br /> j?ES;TRUCTION 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 /> 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED o-( TITLE ��Q. <br /> DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY :t�- <br /> DATE s� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FI AL INSPECTION <br /> INSPECTION BY DATE . INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> Y- :'i .� 1•-7.4 .2M <br />