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SAN JOAQUIN LOCAL HEALTH DISTRICT �nC� <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. / <br /> • Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7 "/�� <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 ADDRESS/LOCATION _CZ4 Qt} : �MMikis- CENSUS TRACT <br /> Owner's Name , S Phone <br /> Address SA m 6 City ;PLOA) <br /> Contractor's Name <br /> `^'' �VQ�✓...,. ....,_._,_�_....—_ License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP-REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES P {P <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,To.ol Dia. of Well Excavation <br /> Dome's tic/private Drilled` ` Dia. of Well ,Casing <br /> .Domestic/public Driven _: Gauge of Casing <br /> Irrigation. . Gravel Pack Depth -of Grout Seal <br /> Cathodic Protection -Rotary Type of Grout f <br /> Disposal 0ti' Other Information. <br /> Geophysicals Surface Seal !Installed BY:o <br /> _�___. <br /> PUMP INSTALLATION: Contractor 0 1�. - <br /> Type of Pump H.P. <br /> PUMP <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 FOIZ A GROUT INSPECTION <br /> PRIOR TO G UTING An AfFINAL 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 GROUT INSPECTION PHA_ IJ!I/FIML INSPECTION <br /> INSPECTION BY DATE _ INSPECTION B DATE 1j,/0 7r� <br /> E H 1426 Rev. - I-74 <br /> 17.7 _ 2M <br />