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Co,��m.��,,��no�a Gv SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F 0 B 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 Sacs oaquin Local Health District. <br /> ,TOB ADDRESS/LOCATION0 A-17'-'57 CENSUS 'TRACT <br /> Owner's Name Phone _ <br /> Address J3 d Yi i / 1 4�> City . U � <br /> Contractor's Name License .?d Phone --76 76 <br /> TYPE OF WORK (Check): I4EW WELL /-7 DEEPEN '/-7 . RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /f CI PiIMP REPLACEMENT /-7 <br /> Other /_7 <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 \(\ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (�15 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ---- Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing d <br /> Irrigation Gravel 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 Z <br /> Type of Pump = H.P. <br /> S� <br /> PUMP REPLACEMENT: . /_7 State Work Done <br /> PUMP ,.REPAIR: /.Zqr State Work Done Gv/ <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..knowl nd-bel ef. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO AND A FI AL INSPECTIO <br /> SIGNED <br /> RAW PO PLAN ON REV SIDE <br /> FOlt"DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE FIIJAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1 -74 h/75 ?M _ <br />