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�® SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> FOR" BICE USE:O ...,. 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 l REAR FROM DATE ISSUED Date Issued <br /> Y.4 <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 Joaquit <br /> County Ordinance No. 1862 aiid the Rules and Regulations of the San Joaquin Local Health District. <br /> 40B ADDRESS/LOCATION <br /> ` CENSUS TRACT <br /> Owner's Name O <br /> I E Phone <br /> E <br /> Address /J011 0 411 <br /> J City <br /> Contractor's Nam4, License <br /> - Phone 1 d , <br /> TYPE OF WORK (Check): NEW WELL '/? DEEPEN /_7 -RECONDITION / DESTRUCTION /7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR 1-7—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 /> Industrial Cable Tool v ` <br /> INTENDED USE TYPE OF <br /> WELL PUBLIC <br /> SPECIFICATIONS <br /> Dia. of Well Excavation � <br /> �� Domestic/private Drilled 'r <br /> 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 <br /> Geophysical - �_ Other Information <br /> _ Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> i,.w. <br /> a Type of Pump ►rt.�`' &2e n VH.P. <br /> h PUMP REPLACEMENT: H/ State Work Done 7:j�ujLv . <br /> PUMPI REPAIR.-- /7 -:-Stare Work, .,e_.. <br /> _ Done <br /> ES; RUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 ati 1 <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 a d bell I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TQ G G AND A FINAL IMECrI6 . <br /> SIGNED <br /> LE <br /> RAW P_ LAN ON SE SIDE <br /> PHASE I FO. ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE elZ <br /> PHASE II GROUT INSPECTION PHASE FINAL INSPECTION <br /> INSPECTION BY DATE _ INSPECTION BY <br /> DATE <br /> J. <br /> } � 1E H 1426 Rev. 1-74 <br />