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k <br /> ell <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTl <br /> FOR.,OFFICE USE:. . q/1601 E. Hazelton Ave. , Stockton, Calif. i <br /> v <br /> Telephone: (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZCJ <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 gu ati:ons of he San Joaquin Local Health District. <br /> JOB ADDRESS/LOCA ION CENSUS TRACT <br /> Owner's Name I Phone ' _ j <br /> Address c ; <br /> City <br /> Contractor's Name License #,20- Phone <br /> V If <br /> - - - � . <br /> TYPE OF WORK (Check): NEW WELL V DEEPEN '/? RECONDITION /7 T <br /> DESTRUCTION f 4 <br /> PUMP INSTALLATION /77 . PUMP REPAIR /-7 PUMP REPLACEMENT_17 <br /> ' DISTANCE TO NEAREST: SEPTIC TANK Q ,< SEWERLINES f - 'PIT PRIVY <br /> SEWAGE'.-DISPOSAL-FIELD CESSPOOL/SEE—PAGE PIT OTHER t <br /> PROPERTY LIN PRIVATE DOMESTIC WEL ",,PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private :---X- Drilled Dia. of Well Casing IT - <br /> f ' Domestic/public Driven Gauge of Casing <br /> Irrigation 1.1 X Gravel Pack Depth of Grout Seal <br /> Cathodic Protection It Rotary _ Type`,of`NGraut ) . <br /> Disposal I Other tither Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump '` A.P. <br /> PUMP REPLACEMENT: . / / `State Work Done <br /> PUMP .-REPAIR: " / / State Work Done -� <br /> DESTRUCTION OF WELL: Well Diameter 411 <br /> 1i Approximate Depth °y <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-:ry"work onAa new well, I will furnish the San Joaquin Local Health District a <br /> 'WELL DRILLERS REPORT ofzthe 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 G OUTING AND A FINAL INSPECTION. f <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUTIINSPECTION PHASE III FINAL INSPECTION <br /> �;NSPECTION BY ;DATE INSPECTION BY w �` DATE <br /> t <br /> P H 1426 Rav- 1-71& r: _ 4/75-—2M <br />