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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO676.FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> THIS PERMIT EXPIRES .l YEAR. FROM DATE ISSUED Date Issued _ <br /> i,-� (Complete In Triplicate) SS- 2-00 o f <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 appXication is made in compliance with San Joaquil <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local stealth District. <br /> JOB ADDRESS/LOCATION —r CENSUS CT =per a <br /> i Owner's Name uJ Ph <br /> ne <br /> Address ! . City '_ <br /> Contractor's Namei�9• License # %% Phone -J <br /> r ii�1� <br /> 4 <br /> TYPE OF WORK (Check): NEW WELL � DEEPEN '/-7 RECONDITION /f DESTRUCTION J f <br /> F PUMP INSTALLATION / / PUMP REPAIR /_7 PUMP REPLACEMENT / ? J <br /> E Other Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY V <br /> -? <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER7' P <br /> + <br /> PROPERTY' LINE-- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL � <br /> i INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 1A !' <br /> k Domestic/public Driven Gauge of Casing <br /> x Irrigation _ �Y Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal - Other Other Information `' <br /> F Geophysical Surface Seal Iristalled 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT <br /> / / State Work Done , <br /> PUMP..REPAIR: State Work Done <br /> DES1TRUCTION OF WELL. Well Diameter, Approximate Depth <br /> Describe Material and Procedure <br /> f <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District ] <br /> atd the State of California pertaining to or regulating well ''construction. Within FIFTEEN DAYS';. - <br /> after completion of my work ona new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting.the..weli. in .use.... The above <br /> information is true to the,best.o . my.knowledge and belief. I WILL CALL 'FOR A 'GROUT INSPECTION <br /> : PRIOR TO MUTING AND A AL IN CTI „ <br /> SIGNEDi AITLE <br /> DRAW LOT PLAN oN REV SE SIDE <br /> DEP TMENT U ONLY <br /> PHASE I 01 <br /> APPLICATION" ACCEPTED BY DATE <br /> { ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 1 4 DATE <br /> k E H 1426 Rev. 1-74 li/75 2M <br /> i -_ <br />