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C SAN j0IN LOCAL HEALTH DISTRICT <br /> FO <br /> ;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i 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 L:L '76 <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> M I <br /> ! Owner's Name Phone iP —4,, <br /> i <br /> 2"j Address � � City <br /> Contractor's Name License # Phone . <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /+7 RECONDITION %r DESTRUCTION f7 <br /> PUMP INSTALLATION / PUMP REPAIR PUMP REPLACEMENT f7 <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 /> r INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well. Excavation <br /> Domestic/private Drilled Dia. of Well Casing b_ <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: MContractor <br /> Type of Pump H�P. <br /> PUMP REPLACEMENT / / State Work Done <br /> .. y <br /> i 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 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 CALLFOR A GROUT INSPECTION <br /> PRIOR TO GR I D A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY - DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II INSPECTION PHASE III/FIAAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY C, DATE 1 <br /> E H 1426 Rev. 1-74 - --. /75 2m <br />