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o /m Aeee SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r Telephone: (209) 466--6781 p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. "—,? <br /> / <br /> I <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 Rules and Regulations of the San Joaquin Local`Health District. <br /> JOB ADDRESSILOCATION ,fj•'re <br /> f _ CENSUS TRACT <br /> Owner's Name '`5 - Phone i <br /> Address '�' ' City ' <br /> Contractor's Name ox-/ License # dY3-phone e ;d <br />. 1 <br /> _ 4 <br /> TYPE OF WORK (Check) ; NEW WELL/ / DEEPEN:'/ J RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /_/ PUMP REPAIR /�/ -PUMP REPLACEMENT /? <br /> Other / / <br /> j 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 /> INTENDED USE . .. .TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> . Domestic/public Driven Gauge ofCasing <br /> Irrigation _. Gravel..Pack Depth of .Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' s <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. . j <br /> PUMP' REPLACEMENT: . / / State Work Done _ <br /> PUMP .REPAIR: �J State Work Done $ r <br /> 3 <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 /> PRIOR. TO GROUTING AND A FINAL INS TIO <br /> SIGNEDZDYAW- PLOTT LAN ON REVERSE SIDE) " � �7 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I SPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY . DATE <br /> E H 1426 Rev, -1-74 <br /> 3/76 2M <br />