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k. AN JOAQUIN'LOCAL HEALTH DISTRICT <br /> a FOFOFFICE USE.: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephonq,: x(X, 9) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 11-17 J6 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> I and/or install the work herein described. This application is made in compliance with San Jonquil <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name `Phone <br /> _ _.. <br /> Address ` <br /> City ' <br /> f Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPENRECONDITION -/ f DESTRUCTION f7 <br /> PUMP INSTALLATION "I / PUMP REPAIR/_7 PUMP REPLACEMENT % f <br /> Other /I <br /> ..DISTANCE TO NEAREST: SEPTIC TANK _ 60,1 SEWER LINES PIT PRIVY 4�c�tc�L <br /> SEWAGE DISPOSAL FIELD �,o CESSPOOL/SEEPAGE PIT OTHER <br /> p <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 //" N <br /> Domestic/private Drilled Dia, of Well Casing _ IL!�/��, W <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Pr-otection k/. Rotary Type of Grout ' y- <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed 'B t <br /> I -PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> j PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: <br /> State Work-Done . . . . .x.�"�..�____� - <br /> DESTRUCTION OF WELL: We-1 ""Diameter Approximate_Depth <br /> .._�,. <br /> _„r1°__,Desc 'ibe Mate ial and Procedure <br /> I hereby agree o comply with all laws and regula ons-of the_San- " " aquin Local Health-.District <br /> and the State of California perttaainii`n-g to,.or-regung e <br /> latiii`-construction,. Within FIFTEEN DAYS <br /> after completia�i,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 TOG UTING AN AL IN CTION <br /> .SIGNED ITLE <br /> r (DRAW T PLAN ON REVR19E SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ', ADDITIONAL COMMENTS: <br /> P I qROUT INSPECTIO PHAS IIF AL INSPECTION <br /> INSPECTION BY DATE ' -ASPECTION BY DATE <br /> E H 1426 Rev. 1-74 h h q 2M <br />