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"d SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOO OFFICE USE: 160'T E. Hazelton Ave. , Stockton, Calif. ��7� <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 <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 <br /> XNo. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION l `Gl— CENSUS TRACT <br /> Owner's Name Phone c5-9V _qz,-�q <br /> Address �'���1,[? Cr�Z`t.ei 7c'/'l _ City <br /> Contractor's Name f 6 1 a License # Phoneme <br /> TYPE OF WORK (Check): NEW WELL/,l DEEPEN/-7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION L-7PUMP REPAIR 1-7-pump REPLACEMENT %f <br /> Other C7- <br /> DISTANCE <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 OF WELL CONSTRUCTION SPECIFICATIONS mm=6 <br /> Industrial Cable Tool Dia. of Well Excavation / v <br /> V_ Domestic/private Drilled Dia. of Well Casing X y <br /> Domestic/public Driven Gauge of Casing AQ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Z Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: T <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> r <br /> PUMP REPLACEMENT. / tate Work Done <br /> PUMP :REPAIR: -7 State Work Done <br /> RES 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 and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING D A2FINAL IMPECTION. <br /> SIGNED i'. J. TITLE C �� <br /> (RYE PLOT LAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE _y-- <br /> E <br /> —E H 1426 Rev. 1-74 1-74 2M <br />