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646 SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOfi OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> EMU APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;W-614r.1 <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 theSanJoaquin Local Health District. <br /> JOB ADDRESS/LOCAT N �� / 'tri FCENSUS TRACT <br /> Owner's Name , Phone <br /> Address /. City <br /> Contractor's Name � 4 License #` Phone <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN/7 RECONDITION / DESTRUCTION f7 <br /> TA <br /> PUMP INSLLATION PUMP REPAIR-/-7-pump REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSM FIELD ,C CE POOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE - TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ le Tool Dia. of Well Excavation <br /> t 8, mastic/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 ,;`1 <br /> Disposal Other Other Information <br /> Geophysical ? Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor yam} s L <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 the-well in use.. The above <br /> information is true to the-bes of£ my.knowledge and belief. I WILL CAJL FOR A GROUT INSPECTION <br /> PRIOR TO GROUA7NCv ANDI FIN SP CTN. <br /> SIGNED TITLE <br /> KD%W, LOT PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY < DATE 2- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION1 <br /> INSPECTION BY/--L-7-Z TE ..s. INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 h/75 2M <br />