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�J <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB'rOFFICE 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 Issued2„�� <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/LOCATION /P 'ri �" /%f. 'l i% /� % ' CENSUS TRACT <br /> Owner's Name Phone V <br /> Address F it "-s-r; City <br /> Contractor's. Name r {;c" X License # Phone �r / <br /> TYPE OF WORK (Check): NEW WELL ,L77- DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION Lam:Pump REPAIR /-7 7PUMP REPLACEMENT <br /> Other L-7 <br /> DISTANCE TO NEAREST: SEPTIC TANKS R-LINES %_"��,s- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE MESTIC WELL _ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ^ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /I ` <br /> ; --60—mestic/private Drilled Dia. of Well Casing rA ate'` <br /> Domestic/public Driven Gauge of Casing <br /> - <br /> --Irrigation L---dravel Pack Depth of Grout Seal - r <br /> Cathodic Protection Rotary Type of Grout -f'a.;� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - -- H.P. CA <br /> PUMP REPLACEMENT.: L7 State Work Done <br /> PUMP .REPAIR: L7 State Work Done _ <br /> r <br /> DES-TT,RUCTION 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 angulating 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..weil in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED _' TITLE <br /> f; <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECT ON <br /> INSPECTION BY e. DATE // 6-7T INSPECTION BY DATE 3/Ei <br /> E H 1426 Rev. 1-74 1-74 2M <br />