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SAN JOA urN LOCAL � ---�-y <br /> ` FOEO ICE USE: HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> A APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br />{ THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> i <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 trade in compliance with San Joaquin <br /> County Ordinance No-` 1862 and the Rules and Regulations of 'the San Joaquin Local Health District. <br /> iI JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name <br /> . - Phone . <br /> Address <br /> City <br /> Contractor's Name . License #/ -Ph <br /> .- one a-2- .1f <br /> 7� <br />` TYPE OF WORK (Check): NEW WELL '/_7 DEEPEN '/? RECONDITION /? DESTRUCTION %j <br /> PUMP INSTALLATION / / PUMP REPAIR /�C� PUMP REPLACEMENT f_7" <br /> Other /% -- <br /> r <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 <br /> Industrial <br /> Domestic/private Cable Tool Dia. of Well Excavation <br /> � <br /> 7 Drilled Domestic/public Dia. of Well Casing <br /> Driven ... Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical 'Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor '] �� e � 1 <br /> Type of Pump A, H.P. / y� <br /> ti <br /> PUMP REPLACEMENT: / / State Work Done C ' <br /> PUMP_'XEPAIR: g State Work Done <br /> ES;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 theca before putting. the..well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO OUTING AND A FINAL SP ON <br /> SIGNE TITLE ,,y <br /> (DRAW PLOT PLAN ON FRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I <br /> APPLICATION ACCEPTED BYDATE-- k <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE&III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE---- <br /> E <br /> ATE —E H 1426 Rev. 1-74 r� ' <br />