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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfltOFFICE 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 7 <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 5- <br /> V 15� F � �/' CENSUS TRACT <br /> Owner's Name Phone 27 <br /> Address :4,-, 7- City <br /> Contractor's Name n v ' _ License # Phone <br /> TYPE OF WORK (Check): NEW WELL W DEEPEN/? RECONDITION /7 DESTRUCTION f j <br /> O�rI ST LATION L� PUMP REPAIR /-7—PUMP REPLACEMENT- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY od <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL =..a <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAIZIONS <br /> Industrial Cable Tool Dia. of Well Excavation (le UN <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /2 <br /> Irrigation Gravel Pack Depth of Grout Seal _ 67) <br /> Cathodic Protection Rotary Type of Grout .. <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: T c2 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: L State Work Done <br /> ,SES-TRII, CTION 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 DRILL REPORT of the well and notify them before putting the..well in use.. The above <br /> information true to thp U f my knowledge and belief. I WILL CALL FOR A GROUT INSP CTION <br /> PRIOR TO jGRMX4NG AL IbtPE CT ION. <br /> SIGNED TITLE <br /> (DRAW PL LAN ON REVERSE SIDE <br /> FOR, DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE JrZ--2-4 <br /> ADDITIONAL COMMENTS: <br /> PHASE14I GROUT INSPECT ON P!AS&4I&&INAL INSPECTION <br /> INSPECTION BY DATE- - <br /> INSPECTION BY DATE - j- <br /> 1 E H 1426 Rev. 1-74 1-74 2M <br />