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- 2e SAN JOAQUIN LOCAL .HEALTH.DISTRICT <br /> FOE OFFICE 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 <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 21Z CENSUS TRACT <br /> Owner's Names C �� �� �,`, Phone <br /> Address city + <br /> Contractor's Name ,. � ,, <br /> ,F.�.R,�► License Phone <br /> T <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/% RECONDITION /�7 DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK ✓f SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /0�0 10 CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE /P PRIVATE DOMESTIC WELL _A PUBLIC DOMESTIC WELL ,._ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 0 <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Z <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection jeO' Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: A ,�e+c- <br /> PUMP INSTALLATION: Contractor Esse <br /> Type of Pump e .._ H.P. <br /> oe <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.A#ork on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPO of the well and notify them before putting the .well in use. The above <br /> informat on i e to the best of my kno ledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO IN j <br /> SIGNED °j" • `�e.. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE j <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION VU PHASX III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY Cn DATE <br /> 1Z7. <br /> E H 1426 Rev. 1-74 <br />