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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: -` 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 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is Aereby 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 end Regulations o the San J aquin Local Health District. <br /> JOB ADDRESS/LOCATION NSUS TRACT <br /> ��, e �Owner's Name y � Phone <br /> Address 1 7-3 /JCr_ 1�1�( 15-4 9 / x �� <br /> -ik-,City . / <br /> Contractor's Name - License �'��/ Phone-3bdp <br /> '3393 <br /> TYPE OF WORK (Check) : NEW WELL /l;;f'DEEPEN / / RECONDITION / /-7_/ DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /-7 <br /> Other <br />'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY w <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 Cable Tool Dia. of Well Excavation 12 1 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/publicDriven 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 - '\ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <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 DRILLERS REPORT of the well and notify them before putting thewell in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIO <br /> PRIOR TO G UTING AND-A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY7:4 �225�!24aeaDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I/FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY TE <br /> �7_P <br /> E H 1426 Rev. 1-74 <br /> , 1177 " 2M <br />