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SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> FOR 0'Fr-�T.CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. I <br /> = Telephone: (209) 466--6.781 <br /> APPLICATION FOR WELI CONSTRUCTION OR PUMP PERMIT Permit No. z <br /> THIS PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED..I 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 a d the Rules e ions. of the San .Toa u' 'L Health -District. <br /> JOB ADDRESS/LOCATION �`?r' �� NSU RACT <br /> o i <br /> Owner's Name If/ �t�TiP.�GL}' Phone <br /> Address City 'J2�� Td.t/ <br /> Contractor's Name ���5 ��, License #2C Phone7y4Z.s' <br /> F <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> --- <br /> DISTANCE TO NEAREST: SEPTIC TANK/,a'' 4 SEWER LINES /07/j PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ; CESSPOOL/SEEPAGE PIT OTHER d <br /> PROPERTY__LINE---=-PRIVATE-DOME S.TI.0 WELL.. _.P_UBLIC. DOMESTIC---WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ti'' Cable Tool 'Dft.-;ofWell Excavation 0 <br /> Domestic/private Drilled Dia. of We 11 Casing _ 04 rr <br /> Domestic/public Driven Gauge of- Casing T <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ��Rotary Type of Groutd/Ylf�'% <br /> Disposal Other Other Information <br /> 4 Geophysical Surface Seal Installed by' <br /> PUMP INSTALLATION: Contractor f <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done ; x <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 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 /> .'EPRIOR TO GROUTIN AND A FINAL INSPECTION. <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> # PHASE I <br /> APPLICATION ACCEPTED BY -�- �j C5DATE <br /> k ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY / DATE/ 3 -- INSPECTION BY DATE <br /> 2M <br /> E H 1426 Rev. , 1-74 io <br />