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b ,. <br /> Ca ►yi (` gtoev_00'SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . Telephone: (209) 466-6781 <br /> tI APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2,6- 122p <br /> r <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 /> f rind/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1.862 and the Rules and Regulations, of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / �V42 CENSUS TRACT <br /> Owner's Name ,a <br /> Phone ' <br /> Address City lw,- <br /> Contractor's NameLicense -Phone <br /> :- - <br /> TYPE OF WORK (Check) .- NEW WELL /7 DEEPEN '/ RECONDITION F7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR &7 PUMP REPLACEMENT J <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPCSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public � 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 By <br /> PUMP INSTALLATION: Contractor v <br /> _r <br /> � , . <br /> Type ..of Pump ✓ e H.P. I� <br /> PUMP REPLACEMENT: / State Work!7j:,.Done <br /> PUMP .REPAIR: /7 .State Work Done <br /> DESTRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Material and Procedures.+.. <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,tfurnish the San. Joaquin Local Health' District a <br /> WELL DRILLERS REPORT of the well and notify them before putiing,ihe..well, in.use.... .The above <br /> information is true to the-best-ofmy..knowled belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO ROUTING AND A FINAL INSPE N. <br /> SIGNED a 4 __TLE & ' <br /> D PLOT PLAN ON RE SE SIDE " <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I� do�-6g , 7G <br /> A PLICATION ACCEPTED BY DATE f 2 oE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H-.4-47, IZ74-. r 1,I7< 9M <br />