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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE 'OFFICE USE: 1601E. Hazelton Ave. , Stockton, Calif. <br />€ Telephone:' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 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 /> kCounty Ordinance No. 1862 and the .Rules and Regulations of the San Joaquin Local Health District. <br /> .FOB ADDRESS/LOCATION, � �.�•3 .. c CENSUS TRACT <br /> ' _- <br /> Owner's Name --2.f�Zr_ - _.,....---.._. Phonel �/7 <br /> Address / !J .CJ .�. 1©. City/ n�/ - <br /> f <br /> Contractor's Name f 4/ e 470 ,� [/�v't /� License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /% DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR /G,L- PUMP REPLACEMENT f� <br /> Other•.I/ / <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY <br /> E SEWAGE °DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTTER � <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL V <br /> I INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (v. <br /> Industrial Ll Cable Tool Dia. of Well Excavation <br /> Domestic <br /> /private �� Drilled Dia. of We11 Casing <br /> Domestic/public Driven Gauge of Casing <br /> c. Irrigation "1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical ,ht , Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done T <br /> PUMP REPAIR: State Work Done 4C1 <br /> t <br /> DES.7ERUCTION 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 do 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 CAL& FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING AND A FINAL! INSPECTION. <br /> SIGNED �. r TITLE <br /> t (DRAW PLOT PLAN ON REVERSE SIDE) <br /> - --FOR ,DEPARTMENT USE ONLY i -_ ._._.. <br />. PHASEI <br />�. APPLICATION ACCEPTED BY.-.. _ —. DATE�- � <br /> ADDITIONAL COMMENTS: t <br /> l PHASE II GROUT INSPECTION PHASE UXFINAY INSPECTION <br /> INSPECTION BY DATE INSPECTION PATE <br /> 2M <br /> E H 1426 Rev. . 1-74 <br /> 6777 <br />