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h SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 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 7 00-r, et.,/ // / �p CENSUS TRACT <br /> Owner's Name Phone �- <br /> Address G-a LC/ City .cc¢ <br /> Contractor's Name a4l.9 License #�� Phone <br /> 6L 3 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/_% RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / �( PUMP REPAIR / / PLfMP REPLACEMENT /7 <br /> Other <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 Cable Tool Dia. of Well Excavation <br /> domestic/private gilled Dia. of Well Casing .� <br /> Domestic/public Driven Gauge of Casing l,. el <br /> Irrigation - Gravel Pack Depth of Grout Seal Is--n <br /> Cathodic Protection L-r Rotary '.Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 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 AND A FINAL 0SP.E01ON. <br /> SIGNS („p TITLE <br /> SE W-YL T PLAN 0�,}I ON 7 <br /> ':. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �/-/ 7" `7 (y <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P SV <br /> �tIFIN14 INSPECTION <br /> INSPECTION BY &vV DATE ���� INSPECTION BY DATE <br /> P­9� <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />