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S <br /> s <br /> ` SAN JOAQUIN LOCAL HEALTH;DISTRICT , <br /> FOF-OFFICE USE: 1601 E. Hazelton Ave. Stockton Calif. <br /> Telephone : (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,�-1a-� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /S 7 gam„ <br /> (Complete In Triplicate) <br /> Application is hereby made toithe 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 andithe Rule and Regulations of the Joaquin Local Health District '" <br /> JO&.:ADDRESS/LOCAT N p� <br /> CENSUS TRACT <br /> C ' <br /> owner's Name PhoneZ ` k <br /> Address City. ' <br /> Contractor's Name / License f�jyz Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN%/ 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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable T001Dia, of Well 'Excavation <br /> Domestic/private Drilled zil Dia." of• Well Casing <br /> Domestic/public F Driven Gauge of Casing. <br /> Irrigation Gravel Pack Dep�fh of Grout" Seal, i <br /> Cathodic Protection i Rotary Typ.6�75f' Grout <br /> Disposal E Other Other Information <br /> Geophysical Surface Seal Instal <br /> 1 - <br /> PUMP INSTALLATION: Contractor , m <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Do 01_a <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 'OF WELL Well Diaiiieterrv+ ._ <br /> 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 knowledge and belief. I WILL iCALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING FIN,L INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY: <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT ON PHASE I /FIN INSPECTION <br /> INSPECTION BY DATE 4 INSPECTION BY GATE <br /> E H 1426 Rev. - I-74 6177 _` <br />