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i <br /> �._ SAN JOAQUZN LOCAL HEALTH DISTRICT <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. <br /> THIS PERMIT EXPIRES I 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 _/� 3 �• /CQ l�eCd/I Zd �� CENSUS TRACT <br /> Owner T s Name Phone <br /> Address City �7 aciC o�y d <br /> Contractor's Name s �,C`, License # . Phone��,�=��o?� <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN j / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR j / PUMP REPLACEMENT <br /> Other <br />.-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 T <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> " omestic/private Drilled Dia. of Well Casing <br /> - - <br /> Domestic/public Driven Gauge of Casing /t15 Q <br /> Irrigation - vel. Pack Depth of Grout Seal " <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP 'INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /tate Work Done <br /> — <br /> -9ta4,.i, W PL <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure .cSil <br /> T <br /> r <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 GROUTIN AND A-FINA <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 2- 7 <br /> ADDITIONAL COMMENTS: <br /> P I G OUT INSPECTION PHA E III/ INAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE 2 -?3 7S <br /> E H 1426 Rev. • -74 <br />