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,no �bR' SAN JOAQUIN LOCAL HEALTH DISTRICT Ce <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 _a _2 <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 Po. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION.` // CENSUS TRACT <br /> Owner's Name Phone <br /> Address 3 s'Z�3 ,/�/� 2 1 J, 4e city <br /> Contractor's Name ` , License1�,37�Phone „ 076 ,7 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR/W PUMP REPLACEMENT /_7 <br /> Other /_7 <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 q,., <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C1 <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 r ' <br /> Type of Pump leb j n C;� H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done 04.1,44 o drf1 l� <br /> DES-TRUCTION 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 the well in use. The above <br /> information is true to the best of my knowledge- belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG UT16G AND A FINAL INSPE (�;� <br /> SIGNED f ITLE D,. , <br /> (DMTPLAN ON R ERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY '� �� 7 <br /> �»� '�� � �.t�, DATE � ��' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSUX410A <br /> INSPECTION BY li ' DATE INSPECTION BY�• c <br /> P 177 <br /> E H 1426 Rev. 1-74 1 2M <br />