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�� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' FO$r0�'F'IC$ USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PULP PERMIT Permit No.,� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application ie 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 _ 14e J .� <br /> CENSUS TRACT <br /> Owner's Name C - -- <br /> ` Phone <br /> Address - - <br /> City 8.v <br /> Contractor's Name License #�_�Phone . <br /> 796/ <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN '/? RECONDITION / ` DESTRUCTION /7 <br /> : P`[JMP INSTALLATION / PUMP REPAIR /RPUMP REPLACEMENT <br /> Other / <br /> DISTANCE TO NEAREST; SEPTIC TANK y <br /> SEWER LINES• PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT_ OAR <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELT, PUBLIC DOME TS IC WELL�� � . <br /> INTENDED USE TYPE OF WELL � � CONSTRUCTION SPECIFICATIONS � <br /> Industrial Gable Tool Dia. of Well Excavation <br /> Domestic/private. Drilled <br /> Dia. of Well Casing � <br /> Domestic/public Driven Gauge,-of Casing O <br /> Irrigation Gravel Pack Depth;of Grout Seal <br /> Cathodic Protection Rotary, Type of Grout <br /> GeoDisphysical Other v--- � Other�Information <br /> p y - Su'rface.Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP..'REPAIR.__ _- <br /> "'Sfia`t--e•te Work'"Donre <br /> it <br /> PF <br /> •.�.. ,..,,__ - ;�;.�- .-�-:,�..,�;,,..r- - �.�.-�.. -; —.. <br /> ES-TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> ia -- <br /> Ihereby agree to comply with all laws District <br /> D <br /> Local Health <br /> and regulations of the San .7aaquin is <br /> and the State of California pertaining to or regulating well construction' Within FIFTEEN Dis DAYS <br /> after completion of my work on a 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 Crue,to the-best'... Of- my-knowledge and belief. I WILL C�77 <br /> L FOR GROUT INSPECTION <br /> PRIOR TO GRO TING AND -FIN _INSPECTION. <br /> SIGNED <br /> -�"�- r<€ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY PHAS III FINAL INSPECTION <br /> DATE INSPECTION BY _ DATE --�� <br /> E H 1426 Rev. 1-74 <br />