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/l- V SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOR tOFFICE LOSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: % ,(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ p <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 .worlk herein described. This application is made in compliance with San Joaquiv <br /> County -Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name '� � �rf�, _ T _ . Phone <br /> I <br /> Address " - <br /> City <br /> I <br /> Contractor'a .Name License # Phone <br /> �I.. <br /> TYPE OF WORK (Check): NEW WELL . DEEPEN /? RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: ,SEPTIC TANK EWER LINES IT PRIVY <br /> SEWAGE DISPOSAL IELD CESSP OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �w <br /> i INTENDED USETYPE OF WELL <br /> � CONSTRUCTION SPECIFICATIONS <br /> Industrial � Cable Tool Dia. of Well Excavation <br /> Domestic/private) Drilled Dia. of Well Casing 1AtI <br /> �_- Domestic/public Driven Gauge of Casing �+ <br /> IrrigatiattI Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal _ Other Other Informatio ` <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ( Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PM !REPAIR: -/7 State Work Done <br /> ES:TRUCTION OF WELL: ,Well Diameter Approximate Depth <br /> ! Describe Material and Procedure <br /> Ihereby agree to comply with all laws and regulationsof the San Joaquin Local Health Distract <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my,ilwork 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 tollthe-best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 1�. TITLE <br /> II: (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY' DATE 3-1,�J <br /> ADDITIONAL COMMENTS• I�_ Q n GPS . <br /> PHA WOUT INSPECTION PHA I INSPECTION <br /> INSPECTION BY ;E `�-' DATE INSPECTION BY 1, DATE <br /> R E H 1426 1-7�4 t 1-74 2M <br />