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SAN JOAQU LOCAL HEALTH DISTRICT <br /> FOR.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> �.a <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMPPe t 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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOC ION v, �� ,c, ,/(�..�� CENSUS TRACT <br /> Owner's New n �' Phone ' '2 7;� <br /> Address C,> City <br /> Contractor's Name License #A623 Phone'C/ - <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /-7 .AZCOX0z=oxf7 DESTRUCTION 17 <br /> PUMP INSTALLATION /- y°T'UMP REPAIR, 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 PUBLICMESTIC 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 /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �J <br /> Type of Pump A�-�-G z��_ H.P. <br /> PUMP REPLACEMENT: L1 State Work Done <br /> PUMP ,REPAIR: <br /> /� State Work Done <br /> P <br /> DESTRUCTION 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 on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLER REPORT of the well and notify them before putting.the..well. in.use.... The above <br /> informati i true to the-best of my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G IN AND NAL INSP CTION. <br /> SIGNED TITLE <br /> DRAW PIAT PLAN ON REVERSE SIDE f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �� <br /> ADDITIONAL COMMENTS:' <br /> PHASE II GROUT INSPECTION, - PHAS711YTHIRM INSPECTION <br /> INSPECTION BY DATE FACTION BY-2Z r., DATE 1 <br /> E H 1426 Rev. 1-74 i 2M <br />