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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OPFICE USE: 1601 E. Hazelton-zAve. , Stockton, Calif. <br /> Telephone : (2,09) 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 /> � 3T3 <br /> JOB ADDRESS/LOCATION f.a7 CENSUS TRACT <br /> Owner's' Namezlkde�c 4-tPhone <br /> Address r ;� City <br /> Contractor's Name 141; License 1 hone 53�3`-So7p <br /> i - <br /> i <br /> TYPE OF- WORK (Check) : NEW WELL DEEPEN %/ RECONDITION / W <br /> _/ DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR '/ / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK l._ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 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 fid_ �TztL __— <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ L>( Rotary Type of Grout ed, <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B -/'y. <br /> PUMP INSTALLATION: Contz—ac tor� <br /> Type of Pump --- - -�S'zr 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'seI 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 GROUTIN D A F AL S <br /> SIGNED <br /> TITLE �r <br /> - <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C, DATE ` <br /> ADDITIONAL COMMENTS: I0 U <br /> PHASE II GROUT INSPECTI_gly PHASE UIUINAL INSPECTDON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> L <br /> E H 1426 Rev. 1-74 1177 2M <br />