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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi OFFICE USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ../3 3 <br /> , <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .7 7f� <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. 186//2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION (p 3� fn lir/ CENSUS TRACT <br /> Owner's Name Phone <br /> Address CP City'� Z <br /> Contractor's Names f�^ License # Phone �C .Z <br /> TYPE OF WORK (Check): NEW WELL / EEPEN '/7 a RECONDITION /_T DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR-/7 PUMP REPLACEMENT 0, GJ <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 <br /> INTENDED USE TYPE WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> yr 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 In€ormation <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump S H.P. 2_ <br /> PUMP REPLACEMENT: /7 State Work Done tddL.��aa7.�.��.df 2 Aa , <br /> PUMP REPAIR: /7 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 Cal ornia pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completio of my ork on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS PORT of a well and no y th fore putting the..well. in use.... The above <br /> information i tru to he est o my. nd be I WILL CALL F0 GROUT INSPECTION <br /> PRIOR TO GRO IN A 1� AL IN E <br /> SIGNED TITLE <br /> �ZAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPAR MENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMKKNTS t <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY � 1a DATE <br /> E H 1426 Rev. 1-74 h/75 2M <br />