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- <br /> { SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: - 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> G Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> Application is hereby made t (Complete In Triplicate) <br /> o 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 Jo4quin <br /> E County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION K/r <br /> d-j's CENSUS TRACT , <br /> Owner's Name t <br /> Phone Lz'B <br /> Address / <br /> City fi Z Pi <br /> Contractor's.tName f <br /> G License Phone 9s� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION/_7 i• <br /> PUMP INSTALLATION /—/ PUMP REPAIR <br /> Other / / / PUMP REPLACEMENT /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINESL <br /> PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL _ � PUBLIC DOMESTIC WELL <br /> INTENDED USE .TYPE :OF...WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial1�Cablee ''ool Dia. of Well Excavation <br />_ Domestic/private T�. Drilled'°` Dia. of Well Casing !/! <br /> .-..Domestic/publicDt <br /> riven, Gauge of Casing <br /> Irrigation Gravel Pack_ ! Depth of GroutSeal � J <br /> Cathodic Protection Rotor � <br /> Disposal y Type of Grout p -OA <br /> Other '° Other Information ' ,-� <br /> Geophysical c c <br /> . 'Surface Seal Installed B : il�� k �.` <br /> PUMP INSTALLATION: Contractor � ;; ,§1 - �} <br /> a <br /> Type of Pump s + ! H.P. � <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-:REPAIR: 'State- Work Done <br />)ES•TRUCTION OF WELL: Well Diameter <br /> 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 /> a.nd 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 /> BELL 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 f <br /> RIOR TO GRO TING AND A AL INSPECTION. <br />;IGNED ` (� <br /> C - I TITLE <br /> PLOT PLAN, REVERSE SIDE) <br />'RASE I <br /> FOR DEPART NTFUSE ONLY <br /> �,..-::r-_�.�._._-�_�-�..-,, ..�,>,�� F <br /> APPLICATION ,ACCEPTED BY � � <br />,DDITIONAL COMMENTS: DATE <br /> \`PHASE II GROUT INSPE TION <br /> NSPECTION BY.' PHAS ' III/FINAL INSPECTION <br /> DATE �f INSPECTION BY DATE` <br /> E H 1426 Rev. 1774aa1177 _ <br />