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_ ;�- SAN 30AQUINI�,OCv� HEALTH DISTRICT ` <br /> OF*Z6'FICE USE: ff// 1601 E! Hazelton Ave. , .Stockton', "C l f. <br /> Telephone: (204) 466-6781 <br /> APPLICATION ��FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 1 -,A5=7) <br /> jj; (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 des�r: ibed. This application is made in compliance with Sen Joaguij <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOC ON . G CENSUS TRACT <br /> Owner's Name Phone ' <br /> AddressCity / <br /> Contractor's Name �` 4 License #e1170 EPY Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN 'I� RECONDITION DESTRUCTION f <br /> # PUMP 'INSTALLATION / /. PUMP REPAIR I� PUMP REPLACEMENT f f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK :i SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD a CESSPOOL/SEEPAGE PIT OTHER <br /> tPROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL . <br /> INTENDED USE TYPE OF WELL kCONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Toole Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven' Gauge of Casing v <br /> Irrigation Gravel Pack �- Depth of Grout Seal <br /> Cathodic Protection Rotary... d Type�'of Grout <br /> Disposal •1Other Other Information � <br /> —Geophysical Surface-Seal"Ins-tAlUd 'B i <br /> I <br /> PUMP INSTALLATION: Contractor . . ' ' <br /> Type ,of -Pump` H.P. E <br /> PUMP REPLACEMENT: . <br /> � LP State Work Done ; <br /> C.PUMP REPAIR: '.�R` l 1 a State Work V Doney, .. - ,. .� _ — <br /> 1DES4RUCTION 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 /> kafter 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 puttingthe.. ell. in.use.. . .The above <br /> information is true to the.best of.lmy.kno edge and belief. I WI L FORA GR6UT INSPECTION <br /> 'PRIOR TO GRO TING ANDA KNAL INSPECTION. <br /> ' SIGNED 1 Q TITLE � - <br /> :ij. (DRA PLOT PL ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> . PHASE I , 4 i <br /> APPLICATION ACCEPTED BYI� DATE'49L <br /> S-/ �` <br /> ADDITIONAL COMMENTS: I� <br /> PHASEJI GROUT INSPECTION i, P III INAL INSPECTION <br /> INSPECTION BYDATE I� INSPECTION BY(4- 7'7 <br /> z <br /> E H 1426 ' Rev. 1-74 �'� - h/7i 2M <br />