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�a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOR OFFICE US <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 �J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.w- `7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM 'DATE ISSUED Date Issued *�Zg <br /> i (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct L <br /> and/or install the. work herein, described. This application is made in compliance. with San Jogquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District`. i <br /> � ` I <br /> JOB ADDRESS/LOCATION : it 1!c ti <br /> -P CENSUS TRACT <br /> Owner's Name Phone - ar <br /> Address' <br /> _ .• - City <br /> Contractor's Name . _ n, [ f License hone <br /> r � <br /> TYPE OF WORK (Check) : NEW WELL /X7_ DEEPEN / J RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / 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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/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 "'- <br /> :Disposal Other Other Information <br /> f,. <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> ` Type of Pump. H.P. <br /> PUMP REPLACEMENT: '._ <br /> State-Work Done <br />?UMP '.REPAIR: / / State Work Done <br /> ­4 r <br />)ES•TRUCTION OF WELL: Well Diameter it l r <br />--� - �.— Approximate Depth <br /> Describe Material and Procedure i <br /> C hereby agree to comply with-0-a'11-laws. and regulations of the San Joaquin Local Health District. <br /> ind the State of California pertaining to or regulating well '-construction. Within FIFTEEN DAYS <br /> Lfter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> BELL DRILLERS REPORT of the well and notify them before putting thewell in use.. The above <br /> n£ormation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTING p <br /> INS I <br /> iIGNED TITLE <br /> ( RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />'HASE I <br /> XPLICATION ACCEPTED BY. DATE <br /> J)DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY DATE = -7 <br /> 2M <br /> E H 1426 Rev. 1-74w <br />